Every finding on record at Health Source Home Care, Inc

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/31/22 through 11/3/22 at: Health Source Home Care. 1100 Owendale Dr. Suite H Troy, MI 48083 This was a standard survey and 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 from 10/31/22 through 11/3/22 at: Health Source Home Care. 1100 Owendale Dr. Suite H Troy, MI 48083 At the time of the survey, this agency had no branch sites. Clinical records reviewed: 4 records with home visits; 6 records without home visits, for a total of 10 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 Part 484.

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 and interview, the agency failed to conduct a comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset, exacerbations, treatments, outcomes, and history of events leading to current home care needs in 4 of 10 records reviewed (MR# 1, 3, 5 and 6), resulting in incomplete clinical information to aid in determining the needs of these patients. Findings included: MR# 5: This 72-year-old patient was admitted to the agency on 9/1/22 with diagnoses which included type 2 Diabetes Mellitus (DM) with chronic foot ulcer on right heel; diabetic neuropathy (damage of nerves related to diabetes); Atrial Fibrillation (irregular heartbeat); and long-term use of insulin and anticoagulants. The clinical record was reviewed on 11/2/22. The comprehensive start of care (SOC) assessment dated 9/1/22 listed the patients diagnoses in section M1021/1023 and included a date of 9/1/22 next to each of the 6 diagnoses listed. There was no indication if the date given was the onset or an exacerbation. Additionally, there was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care within the Comprehensive Assessment. MR# 6: This 74-year-old patient was admitted to the agency on 10/7/22 with diagnoses which included Amyotrophic Lateral Sclerosis (disease affecting nerves and muscle control); cellulitis of right leg (skin infection); urinary catheter use; and prostate cancer. The clinical record was reviewed on 11/1/22. The comprehensive SOC assessment dated 10/7/22 listed the patients diagnoses in section M1021/1023 and included a date of 10/6/22 next to each of the 6 diagnoses listed. There was no indication if the date given was the onset or an exacerbation. Additionally, there was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care within the Comprehensive Assessment. The above findings were reviewed and acknowledged on 11/3/22 at 11:00 a.m. by the Administrator (Admin A) and Clinical Manager (Staff B). MR# 1: The start of care date was 2/3/22, with diagnoses that included cellulitis, hypertension, heart failure and gastro esophageal reflux disease. The clinical record was reviewed on 10/31/22. The comprehensive start of care assessment dated 2/23/22 listed the patients diagnoses in section M1021/1023 and included a date of 2/23/22 next to each diagnosis. There was no indication if the date given was the onset or an exacerbation. Additionally, there was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care within the Comprehensive Assessment. MR# 3: The start of care date was 7/28/22, with diagnoses that included osteoarthritis, hypertension and dementia. The clinical record was reviewed on 11/1/22. The comprehensive start of care assessment dated 7/28/22 listed the patients diagnoses in section M1021/1023 and included a date of 7/28/22 next to each diagnosis. There was no indication if the date given was the onset or an exacerbation. Additionally, there was no documentation of prior treatments, outcomes, or history of how these diagnoses led to the need for home care within the Comprehensive Assessment. The above findings were reviewed and acknowledged on 11/3/22 at 11:00 a.m. by the Administrator (Admin A) and Clinical Manager (Staff B).

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, the agency failed to ensure that the registered nurse completed a comprehensive drug review for 2 of 2 (MR#s 4 and 7) records reviewed for which therapy only cases were assigned, resulting in the potential for undetected harmful medication side effects or interactions. Findings include: MR# 7: This 77-year-old patient was admitted to the agency on 10/21/22 with diagnoses with included aftercare following surgery to low back; lumbar spinal stenosis (narrowing of the opening for the spinal cord in low back); and Parkinson’s Disease. The clinical record was reviewed on 11/1/22. The plan of care (POC) dated 10/21/22 included orders for physical therapy (PT) and occupational therapy. The start of care was dated 10/21/22 and was completed by PT. An agency Patient Medication Profile dated 10/21/22 to 12/19/21 was found in the clinical record but did not include a signature of a reviewing clinician. There were no clinical documentation indicating that the medication profile had been reviewed by a home health registered nurse (RN). Inquiry was made on 11/2/22 at 12:52 p.m. with the Clinical Manager (Staff B) regarding whether a registered nurse completed comprehensive drug reviews for start of care cases in which therapy only services were ordered for potential adverse drug effects and drug reactions, and she stated that the medication profiles for therapy only cases were not being reviewed by an agency RN. This finding was acknowledged also during interview with the Administrator (Admin A) and Staff B on 11/3/22 at 10:55 a.m. MR# 4: The patient was admitted to the agency on 10/21/22, with diagnoses that included chronic kidney disease, peripheral vascular disease and diabetes mellitus. The clinical record was reviewed on 11/1/22. The plan of care (POC) dated 9/23/22 included orders for physical therapy (PT). The start of care was dated 10/21/22 and was completed by PT. There was no clinical documentation indicating a home health registered nurse (RN) had reconciled the medications. Inquiry was made on 11/2/22 at 12:52 p.m. with the Clinical Manager (Staff B) regarding whether a registered nurse completed comprehensive drug reviews for start of care cases in which therapy only services were ordered, for potential adverse drug effects and drug reactions, and she stated the medication profiles for therapy only cases were not reviewed by an agency RN. This finding was also acknowledged during an interview with the administrator (Admin A) and the clinical manager (Staff B) on 11/3/22 at 10:55 a.m.

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, policy review, and interview, the agency failed to ensure the goals on the Plan of Care were objectively measurable to determine the patient's progress towards obtaining goals in 6 of 10 (MR#s 1, 2, 6, 8, 9, and 10) records reviewed potentially resulting in insufficient information to adequately assess patient progress. Findings included: **Agency Policy: "Physician's Plan of Treatment/Change Orders," no review date. The policy states, "The plan of treatment shall include: "Specific discipline, frequency, and duration of services, and measurable outcomes and goals." MR#8: The Start of Care (SOC) was dated 9/28/2022. The Plan of Care (POC) for the certification period 9/28/2022 to 11/26/2022 identified diagnoses of Seizures, Atrial Fibrillation, muscle weakness, difficulty walking, dysphagia, and hypertension. The patient was receiving skilled nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST) services. Goals on the Plan of Care included: "Patient will be free from injury throughout certification period; The patient/caregiver will verbalize understanding on Cardiac diet as evidenced by compliance with diet plan within certification period; Patient/caregiver will verbalize understanding of medications as evidenced by recall of action, dose, side effects, and frequency within certification period. These goals are not objectively measurable to determine the patient's progress towards obtaining the goals. MR#9: The SOC was dated 9/19/2022. The POC for the Certification Period 9/19/22 to 11/17/22 identified diagnoses of Type 2 Diabetes (DM2), Hypertension (HTN), Osteoarthritis of right and left hands, osteoarthritis of right and left ankles and feet. The patient was receiving Skilled Nursing (SN), Physical Therapy (PT), and Occupational Therapy (OT). Upon review of the record, it was noted the goals were not objectively measurable to determine the patient's progress towards achieving the goals. Examples included: "Patient will be free from injury throughout the certification period; The patient/caregiver will verbalize understanding of cardiac/diabetic diet as evidenced by compliance with diet plan within certification period; Patient will demonstrate pain management techniques by third week." These goals are not objectively measurable to determine the patient's progress toward obtaining the goals. MR#10: The SOC was dated 4/29/2022. The POC for the certification period 4/29/22 to 6/27/22 identified diagnoses of Pressure Ulcer of Sacral Region, State 3; Pressure Ulcer of Right Ankle, stage 2; Bilateral Osteoarthritis of knee, Generalized Anxiety, and Hemiplegia Following Cerebral Infarction affecting left dominant side. The patient was receiving Skilled Nursing (SN), Home Health aide (HHa), Physical Therapy (PT), and Medical Social Work (MSW) Services. Upon review of the POC, it was noted the goals were not objectively measurable. Examples included: "Patient will be free from injury throughout certification period, the patient/caregiver will verbalize understanding on cardiac diet as evidenced by compliance with diet plan within certification period; Patient will verbalize understanding of medications as evidenced by recall of action, dose, side effects, and frequency within certification period." These goals are not objectively measurable to determine the patient's progress toward obtaining the goals. These findings were reviewed and acknowledged during an interview with the Administrator (Admin-A) and Clinical Manager (Staff-B) on 11/3/2022 at 1:00 p.m. Staff-B stated, "the staff use the goals offered by our electronic medical documentation system, and not many are measurable." MR# 6: This 74-year-old patient was admitted to the agency on 10/7/22 with diagnoses which included Amyotrophic Lateral Sclerosis (disease affecting nerves and muscle control); cellulitis of right leg (skin infection); urinary catheter use; and prostate cancer. The clinical record was reviewed on 11/1/22. The plan of care dated 10/7/22 included the following examples of skilled nursing (SN) goals: will be free of and/or will not manifest any S/S (signs or symptoms) of UTI (urinary tract infection) throughout certification period; Pt/Pcg (Patient and/or Patient Care Giver) will demonstrate pain management techniques by week ending 10/22/22; Pt/Pcg will verbalize medication regimen for new/changed meds by week ending 11/5/22; skin integrity will be maintained throughout certification period. It was unclear how these goals would be objectively measured by the SN to determine progress toward the goals. These findings were reviewed and acknowledged on 11/3/22 at 10:57 a.m. by the Administrator (Admin A) and Clinical Manager (Staff B). MR# 1: The start of care date was 2/3/22, with diagnoses that included cellulitis, hypertension, heart failure and gastro esophageal reflux disease. During review of the clinical record on 10/31/22, it was discovered that the plan of care (POC) nursing goals were not measurable. One goal stated, "Patient/caregiver will state understanding of disease process/management by week ending 3/11/22." Another stated, "Patient/caregiver will demonstrate proper skin/wound care by 100% [sic] by week ending 4/2/22. There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. MR# 2: The start of care date was 10/20/22, with diagnoses that included knee replacement, wound care and falls. During review of the clinical record on 11/1/22, it was discovered that the plan of care (POC) nursing goals were not measurable. One goal stated, "Patient/caregiver will demonstrate pain management techniques by11/5/22." Another stated, "Patient/caregiver will verbalize understanding of meds being taken by week ending 11/5/22." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. The above findings were reviewed and acknowledged on 11/3/22 at 11:00 a.m. by the Administrator (Admin A) and Clinical Manager (Staff B).

Home health aide assignments and duties CFR(s): 484.80(g)(1) Standard: Home health aide assignments and duties. Home health aides are assigned to a specific patient by a registered nurse or other appropriate skilled professional, with written patient care instructions for a home health aide prepared by that registered nurse or other appropriate skilled professional (that is, physical therapist, speech-language pathologist, or occupational therapist). This STANDARD is not met as evidenced by: Based on record review and interview, it was determined the Registered Nurse (RN) failed to prepare clearly written patient care instructions and include safety precautions on the aide's care plan, in 1 of 3 records in which Home Health Aide (HHa) services were provided (MR# 1) resulting in the potential for the provision of unsafe care and unmet care needs. Findings included: MR# 1: The start of care date was 2/23/22, with diagnoses that included cellulitis, hypertension, heart failure and gastro esophageal reflux disease. During review of the record on 10/31/22, it was discovered that the Home Health Aide (HHa) plan of care (POC) dated 2/23/22, had no oxygen or cardiac precautions documented. The above findings were reviewed and acknowledged on 11/3/22 at 11:00 a.m. by the Administrator (Admin A) and Clinical Manager (Staff B).

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, policy review, and interview, the agency failed to include the name of the facility of which the patient was transferred; failed to document the reason for the transfer; and failed to document notification of the transfer to the patient's physician and if the physician had been sent the transfer summary. Findings included: **Agency Policy: "Transfer/Transfer OASIS," no date. The policy states, "There may be times during the course of care when there is a need for the agency to transfer a patient to a different level of care. The patient's physician will be notified of any transfer and a transfer summary sent to the physician within 2 days of the patient's transfer. When a patient is transferred to another facility, relevant information regarding the patient's condition and care requirements will be provided in writing to the transferring facility and a Transfer OASIS will be completed immediately. Relevant information to be included: date and time of transfer, physician responsible for the home health plan of care, reason for admission to home health, reason for transfer and condition under which transfer occurred, the patient's physical and psychosocial status, types of care/services provided, frequency of services, and progress toward goals. Medications the patient is taking at time of transfer and copy of the patient's record. MR#10: The SOC was dated 4/29/2022. The POC for the certification period 4/29/22 to 6/27/22 identified diagnoses of Pressure Ulcer of Sacral Region, Stage 3; Pressure Ulcer of Right Ankle, stage 2; Bilateral Osteoarthritis of knee, Generalized Anxiety, and Hemiplegia Following Cerebral Infarction affecting left dominant side. The patient was receiving Skilled Nursing (SN), Home Health aide (HHa), Physical Therapy (PT), Occupational Therapy (OT) and Medical Social Work (MSW) Services. Upon review of the record, it was noted the patient was transferred to the hospital on 5/21/22. The SN documented under (M2301): Emergent Care, "Yes, used hospital emergency department with hospital admission", and under (M2310): Reason for Emergent Care, "Other than above reason." However, the SN failed to document the name of the hospital in which the patient was transferred and failed to document the reason the patient had been transferred. In addition, the SN documented in the Transfer OASIS Summary, "Copy of summary sent to physician," however, the SN failed to document the date, or manner in which the transfer summary was sent to the physician. There was no fax receipt or date on the transfer summary to indicate the document was sent within 2 days, and there was no date or written signature of the nurse who documented and sent the summary. These findings were reviewed and acknowledged during an interview with the Administrator (Admin-A) and Clinical Manager (Staff-B) on 11/3/2022 at 1:00 p.m.