Every finding on record at Great Lake Home Care, LLC

On 11/16/2021 through 11/19/2021, the Michigan Department of Licensing and Regulatory Affairs conducted a re-certification survey investigation at Great Lake Home Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare authorized Recertification Survey combined with an Emergency Preparedness Survey were conducted by the Michigan Department of Licensing and Regulatory Affairs on 11/16/2021 through 11/19/2021 at: Great Lake Home Care LLC 30800 Telegraph Road Suite #2815 Bingham Farms, MI 48076 At the time of the survey, the agency did not operate any branch offices. The services the agency provides are: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical Social Work (MSW), and Home Health Aide (HHa) Currently Home Health Aide Services are not being provided to patients. For this survey: 3 home visits with record reviews, 3 active records without a home visit and 2 discharged records were reviewed. For a total of 8 records reviewed. At the conclusion of the survey Standard Level Citations were identified.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) The patient's current health, psychosocial, functional, and cognitive status; This ELEMENT is not met as evidenced by: Based on record review, policy review, and interview, the agency failed to conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset, exacerbations, treatments, and outcomes, history of events leading to current home care needs that included baseline data and measurements in 5 of 8 records reviewed (MR#s 1, 2, 4, 7 & 8), resulting in incomplete clinical information to aid in determining the needs of the patient and determining progress towards goals. Findings included: MR #1: The Start of Care (SOC) was dated 10/4/21. The Plan of Care (POC) for the certification period 10/4/2021 to 12/2/2021 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes (DM2), Hypertension (HTN), Polyneuropathy, Nicotine dependence, Osteoarthritis (OA), Reflux, Obesity, and Anxiety Disorder. Upon review of the comprehensive assessment, it was noted that the Registered Nurse (CM#2) failed to document the patient's past medical history that included dates of onset, exacerbations, treatments, and outcomes that affected the need for the current admission. MR #2: The Start of Care (SOC) was dated 11/3/21. The Plan of Care (POC) identified diagnoses of Chronic Obstructive Pulmonary disease (COPD), Hypertension (HTN), Reflux, Anxiety Disorder, Pain, Chronic Fatigue, Difficulty Walking (DIW) and muscle weakness. Upon review of the comprehensive assessment, it was noted that the Registered Nurse (CM#2) failed to document the patient's past medical history that included dates of onset, exacerbations, treatments, and outcomes that affected the need for the current admission. MR 4: The SOC was dated 10/4/2021. The POC for the certification period10/4/2021 to 12/2/2021 identified diagnoses of Osteoarthritis (OA), History of Transient Ischemic Attack (TIA), Below the Knee Amputation (BKA), Nicotine dependence, HTN, COPD, End Stage Renal Disease with renal dialysis. Upon review of the comprehensive assessment, it was noted that the Registered Nurse (CM#2) failed to document the patient's past medical history that included dates of onset, exacerbations, treatments, and outcomes that affected the need for the current admission. MR 8: The SOC was dated 10/4/2021. The POC identified diagnoses of Osteoarthritis (OA), Pain, Sequelae of Cerebral Vascular Infarction (CVA), Muscle Weakness, Asthma, Diabetes Type 2, HTN, Coronary Artery Disease (CAD), Reflux, Polyneuropathy, and Obesity. Upon review of the comprehensive assessment, it was noted that the Registered Nurse (CM#2) failed to document the patient's past medical history that included dates of onset, exacerbations, treatments, and outcomes that affected the need for the current admission. These findings were reviewed and acknowledged by the Administrator (Adm#1) during an interview on 11/19/21 at 1:00 p.m. MR#7: This patient had a start of care (SOC) date of 9/3/2021 with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. The patient was receiving Skilled Nursing (SN) services at a frequency of 1W1 (once a week times one week), 2W1, and 1W2. On 11/17/21, review of the Start of Care (SOC) Comprehensive Assessment noted under "Integumentary (skin) Status" the following documentation: "patient instructed to keep skin clean, dry and lubricated daily WITH OILS LEFT UPPER ARM FISTULA SHUNT MONITORED BY DAILYSIS CLINICI X3 ABDOMEN WOUNDS WITH ABD DRESSING SCANT AMT OF SEROSANG DRIANAGE." (sic) Further review of the SOC integumentary assessment found no evidence which addressed the following aspects concerning the three documented abdominal wounds: origin type, measurements, wound bed, wound edges, and odor. In addition, the SOC assessment's "Interventions" and "Visit Narrative" sections failed to provide any further information regarding dates on onset, past medical treatments/interventions with outcomes, and measurable data to use as a baseline for future wound care needs for the patient. These findings were reviewed and acknowledged by the Administrator (Adm#1) during an interview on 11/19/21 at 10:10 AM.

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 document review and interview, it was determined the Agency failed to ensure that a Registered Nurse performed a comprehensive review of all medications in 2 of 2 record (MRs #5 & 8) following a resumption of care after hospitalization, from a total of 8 sampled records, resulting in the potential for harmful medication effects for all 28 patients currently serviced by this Agency. Findings included: MR 8: The SOC was dated 10/4/2021. The POC identified diagnoses of Osteoarthritis (OA), Pain, Sequelae of Cerebral Vascular Infarction (CVA), Muscle Weakness, Asthma, Diabetes Type 2, HTN, Coronary Artery Disease (CAD), Reflux, Polyneuropathy, and Obesity. The patient was transferred to a hospital on 10/23/21 due to pain in lower back radiating down the left leg. After a 5-day in-patient hospital admission, a resumption of care (ROC) occurred on 10/28/21. Review of the clinical record failed to find any documented evidence that a medication reconciliation was performed by a Registered Nurse during the ROC visit or thereafter. The Agency failed to ensure the patient's medication list was reconciled as stipulated by the Agency policy referenced above.During an interview on 11/19/21 at 1:00 pm the Administrator confirmed the above findings and stated, "A medication reconciliation should've been done after returning home from the hospital." MR 8: The SOC was dated 10/4/2021. The POC identified diagnoses of Osteoarthritis (OA), Pain, Sequelae of Cerebral Vascular Infarction (CVA), Muscle Weakness, Asthma, Diabetes Type 2, HTN, Coronary Artery Disease (CAD), Reflux, Polyneuropathy, and Obesity. The patient was transferred to a hospital on 10/23/21 due to pain in lower back radiating down the left leg. After a 5-day in-patient hospital admission, a resumption of care (ROC) occurred on 10/28/21. Review of the clinical record failed to find any documented evidence that a medication reconciliation was performed by a Registered Nurse during the ROC visit or thereafter. The Agency failed to ensure the patient's medication list was reconciled as stipulated by the Agency policy referenced above.During an interview on 11/19/21 at 1:00 pm the Administrator confirmed the above findings and stated, "A medication reconciliation should've been done after returning home from the hospital." Agency Policy: "Medication Reconciliation" 8.15.1 (Revised February 2021) stated, "The Agency will reconcile patient's medications at time of admission and on an ongoing basis in order to identify any potential adverse effects and drug reactions..." MR#5: The start of care (SOC) was dated 9/7/21. The Plan of Care (POC) identified diagnoses of osteoarthritis, diabetes-type 2, and sciatica (pain going down the leg from lower back). On 11/18/21, record review noted the patient was transferred to the hospital due to respiratory infection on 10/22/21. After a 6-day in-patient hospital admission, a resumption of care (ROC) occurred on 10/29/21. Review of the clinical record failed to find any documented evidence that a medication reconciliation was performed by a Registered Nurse during the ROC visit or thereafter. The Agency failed to ensure the patient's medication list was reconciled as stipulated by the Agency policy referenced above. During an interview on 11/19/21 at 9:50 AM, the Administrator confirmed the above findings and stated, "I don't see one, it should've been done."

Administrator must: CFR(s): 484.105(b)(1) Standard: Administrator. The administrator must: This STANDARD is not met as evidenced by: Based on documents reviewed and interview, it was determined the Administrator failed to ensure that Federal and State agencies were notified of the Agency's change of address, resulting in the potential for the Agency to be operating out of compliance with Federal requirements. Findings include: During a recertification survey on 11/16/2021, it was discovered the Agency's current address (30800 Telegraph Rd., Suite 2815 Bingham Farms, MI 48025) was different from the address listed in the State of Michigan's database (31471 Northwestern HWY, Suite 2 Farmington Hills, MI 48334). When the Administrator (Adm.#1) was requested to show documentation of an CMS (Centers for Medicare & Medicaid) approval letter recognizing the change of address (COA), Adm.#1 provided an application for Medicare Provider Enrollment Chain and Ownership System (PECOS) dated 4/7/2021. When queried for more documentation from NGS (National Government Services) or an CMS approval letter concerning the COA, Adm.#1 stated, "This is all I have." At the end of survey, no documentation from CMS concerning the COA was received, and no documentation that an 855 application to NGS had been submitted. These findings were reviewed with and acknowledged by Adm.#1 during an interview on 11/19/21 at 9:40 AM. Adm.#1 stated, "I'll make sure to contact CMS directly and get this taken care of."

Responsible for all day-to-day operations CFR(s): 484.105(b)(1)(ii) (ii) Be responsible for all day-to-day operations of the HHA; This ELEMENT is not met as evidenced by: Based on document review, and interview, it was determined the Administrator failed to be responsible for all day-to-day operations of the Home Health Agency, resulting in a lack of supervision of the clinical staff and daily operations. Findings include: Agency Policy: "Medical Record Entries and Authentication" 11.3.1 (Revised March 2018) stated, "All entries in the medical records will be authenticated by staff signature and title. By authenticating entries in the patient's record, staff is validating correctness of the information." On 11/17/2021, a home visit was scheduled for the surveyor to observe skilled nursing services. The Plan of Care (POC) was then requested to review treatments and interventions to be performed during the home visit. However, it was noted no POC existed for the patient (MR#7). The Administrator (Adm#1) was queried as to why, and after a few minutes, it was discovered the patient was never admitted. Adm#1 stated the intake coordinator was mistaken and generated the following visit documentation in the medical record: OASIS SOC visit on 10/21/21; Skilled Nursing (SN) visits on 10/27/21,10/29,11/3, 11/5, and 11/10/21. In addition, an OASIS Discharge, and a SN supervisory visit on 11/17/21 were entered. The Administrator was further queried on 11/17/21 at 11:25 AM, who was responsible for the supervision of MR#7 and ensure entries (10/21/21 through 11/17/21) made into the medical record are accurate. Adm#1 replied, "That would be the Clinical Manager and myself." The Administrator failed to provide oversight to ensure normal business operations were appropriate and accurate.

Skilled services furnished CFR(s): 484.105(f) Standard: Services furnished. Skilled nursing services and at least one other therapeutic service (physical therapy, speech-language pathology, or occupational therapy; medical social services; or home health aide services) are made available on a visiting basis, in a place of residence used as a patient's home. An HHA must provide at least one of the services described in this subsection directly, but may provide the second service and additional services under arrangement with another agency or organization. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to ensure that at least one qualifying service was provided directly by agency employees, resulting in the potential for interruption in continuity of care and unmet care needs. Findings include: On 11/16/21 at 9:30 a.m., during the entrance conference, the Administrator (Adm #1) was asked what services were currently provided by the agency? Adm#1 reported, "We offer Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Medical Social Work (MSW), and Speech Therapy (ST). ADM#1 was asked if they also provide Home Health Aide Services, and the response was "no". When asked if they utilized contract personnel, Adm #1 said "Yes." When asked which services were provided by the contract agency, Adm #1 stated, "We contract SN, PT, OT, ST, and MSW services. When asked to clarify which service was directly provided by the Agency, Adm #1 reported, "Skilled Nursing, our Clinical Manager is a nurse and she sees patients."For further clarification, Adm#1 was asked in addition to your clinical manager, who provides Skilled Nursing Services? The response was, "Assured Home Health Care LLC is contracted to provide Skilled Nursing (SN), Physical Therapy (PT), Physical Therapy Assistant (Pta) Occupational Therapy (OT), Occupational Therapy Assistant (COTA), Speech Therapy, and Medical Social Work Services. Also, PRS Contract Services provides PT, Pta, and Speech Therapy Services. Adm#1 further stated, In the past Assured provided Home Health aide Services, but our agency does not offer that service to our patients anymore." The agency failed to ensure that at least one qualifying service was provided directly by agency employees. During the Entrance Conference, Adm#1 was asked to provide copies of the contracts for review. Adm #1 was unable to locate the requested contracts at the time of the survey, and by the time of the exit on 7/19/21 at 1:00 p.m., the contracts had not been provided for review.These findings were discussed with and acknowledged by Adm #1 at the time of discovery.

Contents of clinical record CFR(s): 484.110(a) Standard: Contents of clinical record. The record must include: This STANDARD is not met as evidenced by: Based on document review and interview, the Agency failed to ensure the clinical record was authenticated for accuracy and correctness by appropriate staff entities in 1 of 8 records (MR#7) from a total sample of 8 records, resulting in having inaccurate information documented in the medical record. Findings included: Agency Policy: "Medical Record Entries and Authentication" 11.3.1 (Revised March 2018) stated, "All entries in the medical records will be authenticated by staff signature and title. By authenticating entries in the patient's record, staff is validating correctness of the information." MR#7: This patient had a start of care (SOC) date of 10/21/2021 with diagnoses which included chronic obstructive pulmonary disease, congestive heart failure, and chronic kidney disease. On 11/17/2021, a home visit was scheduled for the surveyor to observe skilled nursing services. The Plan of Care (POC) was then requested to review treatments and interventions to be performed during the home visit. However, it was noted no POC existed for the patient. The Administrator (Adm#1) was queried as to why, and after a few minutes, it was discovered the patient was never admitted. Adm#1 stated the intake coordinator was mistaken and generated the following visit documentation in the medical record: OASIS SOC visit on 10/21/21; Skilled Nursing (SN) visits on 10/27/21,10/29,11/3, 11/5, and 11/10/21. In addition, an OASIS Discharge, and a SN supervisory visit on 11/17/21 were entered. The Administrator was further queried on 11/17/21 at 11:25 AM, who was responsible for the supervision of MR#7 and ensure entries (10/21/21 through 11/17/21) made into the medical record are accurate. Adm#1 replied, "That would be the Clinical Manager and myself." The Agency failed to ensure documentation for MR#7 was up to date and accurate as stipulated by Agency policy referenced above.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 6 of 8 records reviewed (MR#s 1, 2, 4, 5, 7, and 8) out of a total sample of 8 records reviewed, resulting in difficulty determining the patient's progress toward the achievement of goals. Findings included: MR#5: This patient was admitted to home care on 9/7/21 and was recertified on 11/6/21. The Plan of Care (POC) identified diagnoses of osteoarthritis, diabetes-type 2, and sciatica (pain going down the leg from lower back). On 11/18/21, review of the recertification POC dated 11/6/21, noted a Skilled Nursing (SN) visit frequency of 1W1 (once a week times one week), 2W1, and 1W2. Further review found no evidence of any SN goals listed within the patient's POC. These findings were reviewed and acknowledged by Adm#1 during an interview on 11/19/219 at 1005 AM. The Adm#1 stated, "You're right, I don't see any listed." The Agency failed to ensure SN incorporated objectively measurable goals to ascertain the patient's response to treatments and interventions provided. MR#7: This patient had a start of care (SOC) date of 9/3/2021 with diagnoses which included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and chronic kidney disease (CKD). On 11/17/2021, review of the POC dated 9/3/21 found only one listed SN goal which was documented as; "Patient will attain optimal effectiveness of pain management regimen within 2 weeks." This goal was not written in measurable terms. Further, the POC failed to incorporate any goals which addressed the primary diagnoses of COPD, CHF, and CKD. These findings were reviewed and acknowledged by Adm#1 during an interview on 11/19/21 at 10:15 AM. MR#1: The Start of Care (SOC) was dated 10/4/21. The Plan of Care for the certification period 10/4/21 to 12/2/21 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Type 2 Diabetes (DM2), Hypertension (HTN), Polyneuropathy, Osteoporosis, Reflux, and Anxiety. The patient was receiving Skilled Nursing (SN) services 2xweekx2weeks, and 1xweekx3weeks. A review of the goals on the POC revealed that the goals were not measurable. Examples included: "Free of Covid-19; Pain level decrease, no falls or injuries; Patient following his prescribed diets daily; blood sugar within ranges; Patient/Caregiver demonstrate ability to effectively manage medication regimen by/within time period 10/29/21." These goals are not objectively measurable to determine the patient's progress toward goals. MR#2: The Start of Care (SOC) was dated 11/3/21. The Plan of Care (POC) for the certification period 11/3/21 to 1/1/22 identified diagnoses of Chronic Obstructive Pulmonary Disease (COPD), Hypertension (HTN), Osteoarthritis (OA), Reflux, Pain, Muscle Weakness and Difficulty Walking. The patient was receiving Skilled Nurse (SN) services 2xweekx weeks, and 1xweekx2 weeks, and Medical Social Work services (MSW) for Evaluation. Upon review of the Plan of Care, it was noted the goals were not objectively measurable to determine the patient's progress towards goals. Examples include: "Patient will demonstrate competence with self-management of COPD as evidenced by adherence to medication regimen, ability to identify signs and symptoms necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management by 11/30/21.'; "patient will have working knowledge of disease process, pathophysiology, and exacerbation by 11/30/21."; "Patient will demonstrate competence with self-management of hypertension as evidenced by adherence to medication regimen, ability to identify signs/symptoms necessitating contact with medical professionals, diet regimen guidelines, activity compliance and symptom management by 11/30/21." These goals are not objectively measurable to determine the patient's progress toward goals. MR#4: The Start of Care was dated 10/4/21. The Plan of Care for the certification period 10/4/21 to 12/2/21 identified diagnoses of Osteoarthritis (OA), absence of right leg below the knee amputation; polyneuropathy, Hypertension, (HTN) ; Chronic Obstructive Pulmonary Disease (COPD); End Stage Renal Disease (ESRD) with dependence on renal dialysis) This patient was receiving Skilled Nursing (SN) services 1xweekx1week; Physical Therapy Services (PT) and Speech Therapy Services (ST) for Evaluation and treatment. Examples of the goals on the Plan of Care include: "Physical Therapy Evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician; Patient will have no acute care hospitalizations, ER visits, nor readmissions during this episode." These goals are not objectively measurable to determine the patient's progress toward goals. MR#8: The Start of Care (SOC) was dated 10/4/21. The Plan of Care (POC) for the certification period 10/4/21 to 12/2/21 identified diagnoses of Primary Osteoporosis (OA), Pain, Sequelae of cerebral infarction , Muscle weakness, Asthma, Type 2 Diabetes (DM@), and Hypertension (HTN). This patient was receiving SN services 1 times a week for 1 week, and a Physical Therapy (PT) evaluation. A review of the goals on the POC revealed the goals were not objectively measurable to determine the patient's progress towards goals. The POC included 5 goals as follows: "Free of falls and injuries; Free of Covid-19 Virus; Physical Therapy evaluation will be performed and a plan of care to increase functional independence will be established and countersigned by physician; Patient will have no acute care hospitalizations ER visits, nor readmissions during this episode of care." These goals are not individualized to the patient's needs, nor are they objectively measurable to determine the progress towards goals.

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 transfer summary was sent to the physician/receiving facility within 2 business days of the patient's transfer for 2 of 3 (MR#'s 6, and 8) records in which the patient was transferred to an inpatient facility out of a total of 8 records reviewed, resulting in the physician/receiving facility not having knowledge of the patient's health status at the time of transfer, the physician not having a clear picture of the patient's status at the time of discharge, and the potential for unidentified continuing health care concerns and unmet care needs. Findings include: MR#8: This patient was admitted to the agency on 10/4/21, and a transfer OASIS (outcome and assessment information set) was completed by PT#8 on 10/23/21 due to uncontrolled pain. Record review on 11/19/21 indicated there was no documented evidence a transfer summary was sent to the receiving facility within 2 business days of the patient's transfer. Further, the transfer OASIS failed to include any history with clinical data, treatments furnished, current medications, and outcomes in meeting goals in the plan of care. These findings were reviewed with and confirmed by the Administrator during an interview on 11/19/21 at 1:00 p.m. MR#6: This patient was admitted to the agency on 6/18/21, and a transfer OASIS (outcome and assessment information set) was completed by PT#8 on 8/2/21 due to uncontrolled pain. Record review on 11/18/21 indicated there was no documented evidence a transfer summary was sent to the receiving facility within 2 business days of the patient's transfer. Further, the transfer OASIS failed to include any history with clinical data, treatments furnished, current medications, and outcomes in meeting goals in the plan of care. These findings were reviewed with and confirmed by the Administrator during an interview on 11/19/21 at 10:00 AM.