Every finding on record at Home Care Solutions I I, LLC

From 4/12/23 through 4/14/23, a recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

The following standard level deficiencies were identified during a Re-certification survey conducted by the Acute and Continuing Care Division, Bureau of Survey and Certification on 4/12/2020 through 4/14/2023 at: Home Care Solutions II 30275 W. 13 Mile Rd. Farmington Hills, MI 48334 This agency had no extension sites. Records reviewed: 2 discharged records, 3 records with home visits, 2 records without home visits, for a total of 7 records reviewed. Services offered: Skilled Nursing (SN), Physical Therapy (PT), Occupational Therapy (OT), Speech Therapy (ST), Medical social Work (MSW), and Home Health Aide (HHa).

RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient's return home, or on the physician or allowed practitioner - ordered start of care date. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the initial assessment occurred within 48 hours of referral in 3 of 7 (MR # 2, 5 and 6) records reviewed potentially resulting in initial unmet patient health or safety needs and failed to ensure that a registered nurse conducted the initial assessment to determine immediate care and support needs in 1 of 7 (MR #7) records reviewed for which skilled nursing was requested on the referral resulting in the delay of nursing services. Findings include: MR#2: The Start of Care (SOC) was dated 2/9/2023. The Plan of Care (POC) identified diagnoses of Fracture of right pubis subsequent encounter for fracture with routine healing; Pressure Ulcer of sacral region, stage 3. Type 2 diabetes (DM2), Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Bilateral Hearing Loss, and dependence on oxygen. Upon review of the record, it was noted this patient was referred to the Home Care on 2/3/23 that included orders for Skilled Nursing to provide wound care, Physical Therapy to increase strength, and Occupational Therapy for Activities of Daily Living. There were no orders found in the record that included an order to delay the Start of Care by 6 days after the patient was discharged from the hospital on 2/3/2023. These findings were reviewed and acknowledged during an interview with the Clinical Manager (CM #1), the back-up Clinical Manager (CM #2), and the Scheduler (Staff #1) on 4/14/23 at 12:30 p.m. MR #5: This 74-year-old was admitted to the agency on 2/13/23 with diagnoses which included Schizophrenia (mental disorder which impairs daily functioning); diabetes type 2; and urinary tract infection. The clinical record was reviewed on 4/13/23. The physician referral for home care services was dated and fax stamped on 2/10/23. The start of care (SOC) was completed on 2/13/23 by a registered nurse (RN). There was no documentation that the patient was not available for the SOC visit within 48 hours or requested SOC date later than 48 hours after being referred to the agency for care. MR #6: This 71-year-old was admitted to the agency on 6/15/22 with diagnoses which included arthritis of both knees; high blood pressure; and heart disease. The clinical record was reviewed on 4/13/23. The physician referral for home care services was dated and fax stamped on 6/8/22. The SOC was completed on 6/15/22 (7 days after being referred) by an RN. There was no documentation that the patient was not available for the SOC visit within 48 hours or requested SOC date later than 48 hours after being referred to the agency for care. MR #7: This 68-year-old was admitted to the agency on 3/2/23 with diagnoses which included diabetes type 2; high blood pressure; and arthritis of the right ankle and foot. The clinical record was reviewed on 4/12/23. The physician referral for home care dated 2/27/23 requested the following agency services: RN; physical therapy (PT); occupational therapy; and home health aide. The PT completed the SOC on 3/2/23. The first nursing visit and evaluation was completed by the RN on 3/10/23 (8 days after the start of care). There was no documented reason noted in the clinical record for the delay in nursing care as ordered on the referral. During interview with the Clinical Manager (CM #1) on 4/14/23 at 10:30 a.m., CM #1 stated an RN working for the agency at that time had quit resulting in the agency awaiting a nurse to become available to make the visit. The above findings were reviewed and acknowledged during interview with CM #1, the back-up Clinical Manager (CM #2), and the Scheduler (Staff #1) on 4/14/23 at 10:30 a.m.

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 the registered nurse conducted a review of the patient's medications for any potential adverse effects such as: side effects, drug interactions, and duplicate drug therapy for 1 of 7 (MR# 3) records reviewed. This deficient practice results in the potential for unrecognized adverse effects due to medications that could affect all agency patients. Findings include: MR#3: This patient was admitted to the agency on 2/3/23, with diagnoses of emphysema, respiratory failure, congestive heart failure and dependence on supplemental oxygen. The comprehensive assessment was completed by skilled nursing (SN) on 2/3/23. During record review on 4/12/23, it was noted that the medication/list and medication review both failed to include supplemental oxygen. The start of care (SOC) comprehensive assessment dated 2/3/23, documented a secondary diagnosis under M1023, of dependence on supplemental oxygen. During a home visit on 4/13/23, it was confirmed the patient uses continuous supplemental oxygen. During an interview on 4/14/23 at 10:00 a.m., the Clinical Manager (CM #1) and back-up Clinical Manager (CM #2) acknowledged the above 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 included objectively measurable goals specific to the needs of the patient for 7 (MR's #1, 2, 3, 4, 5, 6, and 7) records, and failed to include reportable parameters for 2 (MR#s 1 and2) records from a total of 7 sampled records reviewed, resulting in the inability to determine the patient's progress towards attaining goals, and when to notify physician of blood sugar results. Findings include: MR #5: This 74-year-old was admitted to the agency on 2/13/23 with diagnoses which included Schizophrenia (mental disorder which impairs daily functioning); diabetes type 2; and urinary tract infection. The plan of care (POC) dated 2/13/23 was reviewed on 4/13/23. Examples of skilled nursing goals on the POC included: The patient will verbalize understanding of medication management within this cert period; The patient/caregiver will verbalize understanding of (vital signs) within normal limits and all aspects of associated care within 7 weeks period of time; The patient’s skin and mucous membranes (related to endocrine diagnosis) will remain intact for this cert period.” It was unclear how these goals would be objectively measured by the skilled nurse to determine progress toward the goals. MR #6: This 71-year-old was admitted to the agency on 6/15/22 with diagnoses which included arthritis of both knees; high blood pressure; and heart disease. The POC dated 6/15/22 was reviewed on 4/13/23. Examples of skilled nursing goals on the POC included: The patient will reach maximum functional potential (related to cardiopulmonary/hematology diagnosis) and all aspects of associated care within (blank) period of time; Patient will have Activities of Daily Living met, as evidenced by (blank) within (blank) period of time; Reduce patient fall risk; The patient’s pain will be controlled and managed at the patient’s own comfort level as verbalized by the patient within 5 weeks. It was unclear how these goals would be objectively measured by the skilled nurse to determine progress toward the goals. MR #7: This 68-year-old was admitted to the agency on 3/2/23 with diagnoses which included diabetes type 2; high blood pressure; and arthritis of the right ankle and foot. The POC dated 3/2/23 was reviewed on 4/12/23. Examples of the skilled nursing goals on the POC included: The patient/caregiver will verbalize understanding of (related to cardiopulmonary/hematology diagnosis) and all aspects of associated care within 7 weeks period of time (sic); Client will understand the intervention and management program to manage his constipation; The patient’s pain will be controlled and managed at the patient's own comfort level as verbalized by the patient/caregiver within 7 weeks period of time. It was unclear how these goals would be objectively measured by the skilled nurse to determine progress toward the goals. The above findings were reviewed and acknowledged during interview with the Clinical Manager CM #1, the back-up Clinical Manager CM #2, and the Scheduler, Staff #1 on 4/14/23 at 10:30 a.m. MR #3: This patient was admitted to the agency on 2/3/23, with diagnoses of emphysema, respiratory failure, congestive heart failure and dependence on supplemental oxygen. During record review on 4/12/23, it was noted that the skilled nursing (SN) goals on the plan of care (POC) were not measurable. One goal stated, "Patient/caregiver will understand the signs/symptoms and risk factors related to COVID-19." Another stated, "The patient/caregiver will verbalize understanding of (Vital signs) within normal limits parameters, and all aspects of associated care within 6 weeks period of time." It was unclear how these goals could be objectively measured by the skilled nurse to determine progress toward the goals. MR #4: This patient was admitted to the agency on 1/21/23, with diagnoses of Glossitis, Alzheimer's, congestive heart failure and type 2 diabetes mellitus. During record review on 4/13/23, it was noted that the SN goals on the POC were not measurable. One goal stated, "Patient/caregiver will verbalize understanding of medication management and all aspects of associated care within certification period." Another stated, "The patient/caregiver will verbalize understanding of all aspects of associated care within certification period." It was unclear how these goals could be objectively measured by the skilled nurse to determine progress toward the goals. During an interview on 4/14/23 at 10:00 a.m., the Clinical Manager (CM #1) and back-up Clinical Manager (CM #2) acknowledged the above findings. MR#1: The Start of Care (SOC) was dated 3/15/2023. The Plan of Care (POC) for the certification period 3/15/2023 to 5/13/2023 identified diagnoses of Hemiplegia and hemiparesis following cerebral Infarction affecting the non-dominant side; Diabetes type 2 (DM2), Congestive Heart Failure (CHF), and history of falling. Upon review of the Plan of Care, it was noted the goals were not objectively measurable. Examples include: "Patient/caregiver will verbalize understanding of diabetes and all aspects of associated care within 7 weeks period of time; The patient's pain will be controlled and managed at the patient's own comfort level as verbalized by the patient/caregiver within 7 weeks period of time; The patient/caregiver will verbalize understanding of safety measures and all aspects of associated care within 7 weeks period of time." These goals are not objectively measurable to determine the patient's progress towards goals. In addition, the Plan of Care failed to include reportable parameters to guide the nurse of when to notify the physician of the status of the patient's blood sugar results for this patient diagnosed with diabetes and currently prescribed 2 injectable insulins daily as follows: Humalog 10 units daily after lunch; and Lantus 15 units BID daily. MR#2: The Start of Care (SOC) was dated 2/9/2023. The Plan of Care (POC) identified diagnoses of Fracture of right pubis subsequent encounter for fracture with routine healing; Pressure Ulcer of sacral region, stage 3. Type 2 diabetes (DM2), Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Bilateral Hearing Loss, and dependence on oxygen. Upon review of the record, it was noted the goals on the plan of care were not objectively measurable to determine the patient's progress toward attaining the goals. Examples included: "Patient will have ADLS (Activities of Daily Living) met as evidenced by CGA (Comprehensive Geriatric Assessment) level within 7 weeks period of time; The patient /caregiver will verbalize understanding of prevention of hospitalization and all aspects of associated care within 7 weeks period of time; The patient's pain will be controlled and managed at the patient's own comfort level as verbalized by the patient/caregiver within 7 weeks of time." These goals are not objectively measurable to determine the patient's progress towards achieving the goals. In addition, the Plan of Care failed to include reportable parameters to guide the nurse of when to notify the physician of the status of the patient's blood sugar results for this patient diagnosed with diabetes and currently prescribed both oral diabetic medications and injectable insulin 4 times daily. These findings were reviewed and acknowledged during an interview with the Clinical Manager (CM #1), the back-up Clinical Manager (CM #2), and the Scheduler (Staff #1) on 4/14/23 at 12:30 p.m.

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, the agency failed to ensure the registered nurse included safety precautions on the home health aide (HHa) care plan. This deficient practice results in the potential for injury, that could affect all agency patients. Findings include: MR#3: This patient was admitted to the agency on 2/3/23, with diagnoses of emphysema, respiratory failure, congestive heart failure and dependence on supplemental oxygen. The comprehensive assessment was completed by skilled nursing (SN) on 2/3/23. During record review on 4/12/23, it was noted that the HHa care plan failed to include oxygen precautions. During an interview on 4/14/23 at 10:00 a.m., the Clinical Manager (CM#1) and back-up Clinical Manager (CM#2) acknowledged the above findings.

Assure patient needs are continually assessed CFR(s): 484.105(c)(4) Assuring that patient needs are continually assessed, and This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure the patient's wound was measured to determine the status of wound healing in 1 of 7 (MR#2) records reviewed, and failed to assess the patient's blood sugar results while providing care, resulting in the inability to ensure the wound was healing and the patient's blood sugar results were controlled. Findings included: MR#2: The Start of Care (SOC) was dated 2/9/2023. The Plan of Care (POC) identified diagnoses of Fracture of right pubis subsequent encounter for fracture with routine healing; Pressure Ulcer of sacral region, stage 3. Type 2 diabetes (DM2), Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Bilateral Hearing Loss, and dependence on oxygen. Upon review of the record, it was noted that the Comprehensive assessment, dated 2/9/2023 failed to include a baseline measurement of the patient's pressure ulcer to determine the healing status of the wound during future assessments. It was observed during a survey home visit on April 12th, 2023, with the skilled nurse, (CM#2), that CM#2 failed to measure the wound. In addition, a review of the 19 Skilled Nurse visit notes dated between February 9th, 2023, and April 13th, 2022, failed to include any measurements of the patient's wound. The agency failed to perform measurements during on-going assessments of the patient's wound to determine the healing status of the wound. In addition, the patient was diagnosed with Type 2 Diabetes. The plan of care identified the patient was taking 2 medications to control the patient's diabetes which included Lispro injections on a sliding scale four times a day, and an oral medication, Glimepiride 2 mg twice daily before meals. However, a review of the nursing notes failed to include any daily blood sugar results, nor was the patient's range of blood sugar measurements included in the Comprehensive Assessment. These findings were reviewed and acknowledged during an interview with the Clinical Manager (CM #1), the back-up Clinical Manager (CM #2), and the Scheduler (Staff #1) on 4/14/23 at 12:30 p.m.

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 the comprehensive assessment accurately reflected the patient's current baseline health status in 2 (MR#1 and 2) of a total of 7 records reviewed, resulting in the inability to determine the patient's current health status and needs, and the inability to determine if the patient's health is improving throughout the course of care. Findings included: MR#1: The Start of Care (SOC) was dated 3/15/2023. The Plan of Care (POC) for the certification period 3/15/2023 to 5/13/2023 identified diagnoses of Hemiplegia and hemiparesis following cerebral Infarction affecting the non-dominant side; Diabetes type 2 (DM2), Congestive Heart Failure (CHF), and history of falling. Upon review of the Comprehensive Assessment dated 3/15/2023 and documented by the registered nurse (CM#2), it was noted that essential information was missing from the Comprehensive Assessment. Missing elements included: Vital signs, including blood pressure, heart rate, temperature, respiratory rate, baseline height and weight, breath sounds, oxygen saturation, current blood sugar results, and assessment and measurement of lower extremity edema due to the patient's diagnosis of Congestive Heart Failure. MR#2: The Start of Care (SOC) was dated 2/9/2023. The Plan of Care (POC) identified diagnoses of Fracture of right pubis subsequent encounter for fracture with routine healing; Pressure Ulcer of sacral region, stage 3. Type 2 diabetes (DM2), Hypertension, Chronic Obstructive Pulmonary Disease (COPD), Bilateral Hearing Loss, and dependence on oxygen. Upon review of the Recertification Comprehensive Assessment dated 4/6/2023, it was noted under the category of Endocrine, there was no documentation of the patient's normal blood sugar ranges, however the Skilled Nurse documented "yes, within normal limits" in the Recertification Comprehensive Assessment. In addition, under the category of Diabetic Conditions, the Skilled Nurse documented, "Oral Hypoglycemic Agent", however, the drug review and plan of care indicated the patient was also prescribed Lisinopril, a form of insulin that is injected. Also, there were no reportable parameters to report to the physician nor safety measures identified under the category of Endocrine. These findings were reviewed and acknowledged during an interview with the Clinical Manager (CM #1), the back-up Clinical Manager (CM #2), and the Scheduler (Staff #1) on 4/14/23 at 12:30 p.m.