Every finding on record at Home Health Care Connections, L L C

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/3/23 through 10/4/23 at: Senior Home Care Connections 2075 Fort St. Suite 200 Lincoln Park, MI 48146 The agency had no additional locations at the time of the survey. For this survey no home visits were available (No active patients). 6 discharged records were reviewed. This was a standard survey. The conditions of participation for Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/3/23 through 10/4/23 at: Senior Home Care Connections 2075 Fort St. Suite 200 Lincoln Park, MI 48146 The agency had no additional locations at the time of the survey. For this survey no home visits were available (No active patients). 6 discharged records were reviewed. At the conclusion of the survey the agency was found to be out of compliance at the standard level, for the conditions of participation for home health agencies at: 42 CFR Part 484.

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 visit was completed within 48 hours of the referral or within 48 hours of the patient's return home in 2 of 6 (P-5, P-6) records reviewed. Findings include: P-5: This 68-year-old patient was admitted to home care on 3/8/23 with a diagnosis of low back pain and difficulty walking. During record review on 10/3/23 at 2:05 p.m., it was noted that the physician order for home care was dated 2/20/23. The date stamp of the faxed order states received on 2/20/23 at 4:04 p.m., with a handwritten note changing the date received to 3/6/23 at 2:30 p.m. The start of care assessment was conducted 16 days after the date of the referral. There was no documentation found in the record that the physician had been notified for the reason for the delay. During interview with the administrator (ADM-1) on 10/4/23 at 2:25 p.m., ADM-1 stated they requested additional information from the physician. On 3/6/23, additional records were received (14 days after the initial referral) and the start of care was conducted two days later. P-6: This 55-year-old patient was admitted to home care on 4/11/23 with a diagnosis of degenerative joint disease of the right knee, neuropathy, and depression. During record review on 10/4/23 at 9:35 a.m., it was noted that the physician order for home care was dated 4/5/23. The date stamp of the faxed order states received on 4/5/2023 at 2:38 p.m., with a handwritten note changing the date received to 4/10/23 at 2:35 p.m. The start of care assessment was conducted 6 days after the date of the referral. There was no documentation found in the record that the physician had been notified for the reason for the delay. These findings were reviewed and acknowledged by ADM-1 during an interview on 10/4/23 at 2:25 p.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 comprehensive assessment included an accurate review of all medications to determine potential adverse effects or duplicate drug therapy in 5 of 6 (P-1, P-3, P-4, P-5, P-6) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: Policy: Medication Monitoring/Orders/Teaching/Documentation Rev 08/09, states "Agency staff shall check all medications the client is taking to identify and promptly report to the physician any significant side effects or contraindications including the following. Also agency staff is encouraged to use Drugs.com to find out potential interaction. Only severe interaction medication will be reported to the physicians..." P-4: This 81-year-old patient was admitted to home care on 4/28/23 with a diagnosis of lumbar spinal stenosis and abnormal gait. During record review on 10/3/23 at 12:05 p.m., there was no documentation found in the record of a medication interaction or duplicate drug therapy report. During interview with the administrator (ADM-1) on 10/4/23 at 2:25 p.m., ADM-1 went into another office and returned with another file for the same patient that included a medication interaction report, with the print date of 10/4/23. P-5: This 68-year-old patient was admitted to home care on 3/8/23 with a diagnosis of low back pain and difficulty walking. During record review on 10/3/23 at 2:05 p.m., there was no documentation found in the record of a medication interaction or duplicate drug therapy report. P-6: This 55-year-old patient was admitted to home care on 4/11/23 with a diagnosis of degenerative joint disease of the right knee, neuropathy, and depression. During record review on 10/4/23 at 9:35 a.m., there was no documentation found in the record of a medication interaction or duplicate drug therapy report. The above findings were reviewed and acknowledged by ADM-1 and clinical manager (CM-1) during an interview on 10/4/23 at 2:25 p.m. P-1: The start of care (SOC) was dated 5/2/23 with diagnoses of degenerative disk disease, chronic obstructive pulmonary disease, and hypertension. During record review on 10/3/23, a medication profile dated 5/2/23, was reviewed. The medication profile indicated no adverse effects, significant drug interactions, duplicate/ineffective drug therapy or potential contraindications. The agency does not utilize an electronic system for drug reconciliation/review. When the drugs were entered into Drugs.com, 6 moderate interactions, 2 minor and 1 major food and drug interaction was found. There was no documented evidence in the record that a medication reconciliation was performed. P-3: The SOC was dated 10/31/22 with diagnoses of degenerative disk disease, weakness, and falls. During record review on 10/4/23, a medication profile dated 5/2/23, was reviewed. The medication profile indicated no adverse effects, significant drug interactions, duplicate/ineffective drug therapy or potential contraindications. The agency does not utilize an electronic system for drug reconciliation/review. When the drugs were entered into Drugs.com, 9 moderate interactions, and 2 duplicate drug therapies were found. There was no documented evidence in the record that a medication reconciliation was performed. During an interview on 10/4/23 at 3:15 p.m., the administrator (ADM-1) and the clinical manager (CM-1) 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 covered all safety measures and objectively measurable goals specific to the individualized needs of the patient in 6 (P- 1, 2, 3, 4, 5, 6) records, from a total of 6 sampled records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-1: The start of care (SOC) was dated 5/2/23 with diagnoses of degenerative disk disease, chronic obstructive pulmonary disease, and hypertension. During record review on 10/3/23, it was noted that the goals on the plan of care (POC) were not measurable, for example, one goal stated, "Demonstrates the use of non-pharmacological approaches when appropriate for helping to control pain." Another stated, "Demonstrates compliance with medications by 6/20/23." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-2: The SOC was dated 11/9/22 with diagnoses of degenerative disk disease, hip pain, and polyarthritis. During record review on 10/3/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Demonstrates competence in following medical regime by 1/9/23." Another stated, "Stabilization of cardiovascular, pulmonary system by 1/9/23." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. P-3: The SOC was dated 10/31/22 with diagnoses of degenerative disk disease, weakness, and falls. During record review on 10/4/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, "Demonstrate independence and remain safe in home by 12/31/22." Another stated, "Verbalizes understanding to schedule analgesic medications to keep pain under control." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 10/4/23 at 3:15 p.m., the administrator (ADM-1) and the clinical manager (CM-1) acknowledged the above findings. P-4: This 81-year-old patient was admitted to home care on 4/28/23 with a diagnosis of lumbar spinal stenosis and abnormal gait. During record review on 10/3/23 at 12:05 p.m., it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “Demonstrates the use of non-pharmacological approaches when appropriate for helping to control pain.” Another stated, “Demonstrates compliance with medication by 6/20/23.” There was no evidence of how these goals could be objectively measured to determine progress toward goals. P-5: This 68-year-old patient was admitted to home care on 3/8/23 with a diagnosis of low back pain and difficulty walking. During record review on 10/3/23 at 2:05 p.m., it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “Demonstrates the use of non-pharmacological approaches when appropriate for helping to control pain.” Another stated, “Demonstrates compliance with medication by 5/1/23.” There was no evidence of how these goals could be objectively measured to determine progress toward goals. P-6: This 55-year-old patient was admitted to home care on 4/11/23 with a diagnosis of degenerative joint disease of the right knee, neuropathy, and depression. During record review on 10/4/23 at 9:35 a.m., it was noted that the plan of care failed to include measurable nursing goals that are individualized to address patient needs. For example, one goal stated, “Demonstrates the use of non-pharmacological approaches when appropriate for helping to control pain.” Another stated, “Demonstrates compliance with medication by 6/1/23.” There was no evidence of how these goals could be objectively measured to determine progress toward goals. The above findings were reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/4/23 at 2:25 p.m.

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 detailed discharge summary was sent to the physician within 5 business days of discharge for 6 of 6 (P-1, P-2, P-3, P-4, P-5, P-6) discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-4: This 81-year-old patient was admitted to home care on 4/28/23 with a diagnosis of lumbar spinal stenosis and abnormal gait. During record review on 10/3/23 at 12:05 p.m., it was noted that the patient was discharged from agency services on 6/17/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. During interview with the administrator (ADM-1) on 10/4/23 at 2:25 p.m., ADM-1 shared an interim order for home care within the record that they state serves as the discharge summary. This order failed to include discharge date, type of services provided and frequency of visits, medications the patient was on at the time of discharge, patients discharge condition, patient outcomes in meeting the goals in the plan of care, and post-discharge instructions. P-5: This 68-year-old patient was admitted to home care on 3/8/23 with a diagnosis of low back pain and difficulty walking. During record review on 10/3/23 at 2:05 p.m., it was noted that the patient was discharged from agency services on 4/25/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. P-6: This 55-year-old patient was admitted to home care on 4/11/23 with a diagnosis of degenerative joint disease of the right knee, neuropathy, and depression. During record review on 10/4/23 at 9:35 a.m., it was noted that the patient was discharged from agency services on 5/25/23. There was no documented evidence that a detailed discharge summary report was sent to the physician within 5 days of the patient’s discharge. These findings were reviewed and acknowledged by ADM-1 during an interview on 10/4/23 at 2:25 p.m. P-1: The start of care (SOC) was dated 5/2/23, with diagnoses of degenerative disk disease, chronic obstructive pulmonary disease, and hypertension. During record review on 10/3/23, it was noted that the record contained a discharge OASIS dated 6/13/23. The discharge OASIS failed to include frequency of visits, medications the patient was on at the time of discharge, patients discharge condition, patient outcomes in meeting the goals in the plan of care, and post-discharge instructions. There was no evidence of a discharge summary in the record. P-2: The SOC was dated 11/9/22, with diagnoses of degenerative disk disease, hip pain, and polyarthritis. During record review on 10/3/23, it was noted that the record contained a discharge OASIS dated 12/30/22. The discharge OASIS failed to include frequency of visits, medications the patient was on at the time of discharge, patients discharge condition, patient outcomes in meeting the goals in the plan of care, and post-discharge instructions. There was no evidence of a discharge summary in the record. P-3: The start of care (SOC) was dated 10/31/22, with diagnoses of degenerative disk disease, weakness, and falls. During record review on 10/4/23, it was noted that the record contained a discharge OASIS dated 6/13/23 and an Interim Order for Home Care document dated 4/18/23, that the administrator (ADM-1) identified as the discharge summary. The discharge OASIS and the Interim Order for Home Care document, failed to include frequency of visits, medications the patient was on at the time of discharge, patients discharge condition, patient outcomes in meeting the goals in the plan of care, and post-discharge instructions. During an interview on 10/4/23 at 3:15 p.m., ADM-1 and the clinical manager (CM-1) acknowledged the above findings.

Authentication CFR(s): 484.110(b) Standard: Authentication. All entries must be legible, clear, complete, and appropriately authenticated, dated, and timed. Authentication must include a signature and a title (occupation), or a secured computer entry by a unique identifier, of a primary author who has reviewed and approved the entry. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to ensure documents in the clinical records were legible, clear, complete, and appropriately authenticated with a signature and title, dated, and timed in 1 of 6 (P-4) records reviewed, resulting in records that are not authenticated, accurate, timely, and do not portray the care provided by the agency. Findings include: P-4: This 81-year-old patient was admitted to home care on 4/28/23 with a diagnosis of lumbar spinal stenosis and abnormal gait. During record review on 10/3/23 at 12:05 p.m., it was noted that the skilled nurse visit notes contained multiple handwritten corrections. The visit dated 5/8/23 has a crossed off typed date, replaced with a handwritten date. The record also contained two visit notes dated 5/22/23, one with handwritten corrections of visit date, the other copy displayed the corrected dates. The visit dated 6/5/23 also contained handwritten corrections of visit date. All three of these visit notes failed to include the RN signature (only included typed name of RN). This record was also found to contain records belonging to another patient of this agency including a physician order, plan of care, physical therapy visit notes, and a sheet containing the visit dates and patient signature. The finding was reviewed and acknowledged by the administrator (ADM-1) during an interview on 10/4/23 at 2:25 p.m.