Every finding on record at Home Pro Care, Inc

A Medicare authorized recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/10/23 through 10/12/23 at: Home Pro Care 27908 Orchard Lake Rd., Suite A Farmington Hills, MI 48334 The agency had no other locations at the time of the survey. 7 records were reviewed: 2 discharge records, 1 active with home visit (Only 1 home visit was available), and 4 active records. This was a standard survey, the conditions of participation for emergency preparedness were not reviewed.

A Medicare authorized recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/10/23 through 10/12/23 at: Home Pro Care 27908 Orchard Lake Rd., Suite A Farmington Hills, MI 48334 The agency had no other locations at the time of the survey. 7 records were reviewed: 2 discharge records, 1 active with home visit (Only 1 home visit was available), and 4 active records. At the conclusion of the survey, the agency was found to be out of compliance, at the standard level, with the conditions of participation at 42 CFR Part 484, home health care.

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 1 of 7 (P-4) records reviewed. Findings include: P-4: This 77-year-old patient was admitted to home care on 3/4/23 with a diagnosis of type 2 diabetes, osteoarthritis, and recent pacemaker insertion. During record review on 10/10/23 at 1:00 p.m., it was noted that the physician order for home care was dated 1/6/23. The start of care assessment was conducted 56 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. This finding was reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/12/23 at 1:00 p.m.

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 ensure the comprehensive assessment accurately reflected the patient's current health status at the time of admission to home care for 1 of 7 (P-6) records reviewed, resulting in incomplete clinical information to aide in determining the needs of the patient and for measuring progress toward goals/outcomes. Findings include: P-6: This 82-year-old patient was admitted to home care on 8/30/23 with a diagnosis of hypertensive heart disease and congestive heart failure. During record review on 10/11/23 at 1:30 p.m., it was noted that the initial RN assessment failed to include an actual weight to accurately monitor potential worsening of congestive heart failure. This finding was reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/12/23 at 1:00 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 7 of 7 (P-1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in the potential for harmful medication effects for all patients serviced by this agency. Findings include: P-4: This 77-year-old patient was admitted to home care on 3/4/23 with a diagnosis of type 2 diabetes, osteoarthritis, and recent pacemaker insertion. During record review on 10/10/23 at 1:00 p.m., it was noted that the initial RN assessment stated (under M2001 Drug Regimen Review) that “yes – issues found during review.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during review. P-5: This 66-year-old patient was admitted to home care on 9/22/23 with a diagnosis of bilateral osteoarthritis of the knees and chronic obstructive pulmonary disease (COPD). During record review on 10/11/23 at 10:30 a.m., it was noted that the initial RN assessment stated (under M2001 Drug Regimen Review) that “yes – issues found during review” while the patient medication record indicated there were no interactions or discrepancies. The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during review. P-6: This 82-year-old patient was admitted to home care on 8/30/23 with a diagnosis of hypertensive heart disease and congestive heart failure. During record review on 10/11/23 at 1:30 p.m., it was noted that the initial RN assessment stated (under M2001 Drug Regimen Review) that “yes – issues found during review” while the patient medication record indicated there were no interactions or discrepancies. The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during review. P-7: This 66-year-old patient was admitted to home care on 8/25/23 with a diagnosis of essential hypertension and chronic pain. During record review on 10/11/23 at 3:15 p.m., it was noted that record failed to include a medication interaction or duplicate drug therapy report. These findings were reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/12/23 at 1:00 p.m. MR#1: The start of care (SOC) was dated 4/4/23, with diagnoses that included type 2 diabetes mellitus, and hypotension. During record review on 10/10/23, it was noted that the initial RN comprehensive assessment stated (under M2001 Drug Regimen Review), “Yes, issues found during review.” The record failed to include a medication interaction or duplicate drug therapy report, or any documentation related to the issues found during review. MR#2: The start of care (SOC) was dated 9/5/23, with diagnoses that included hypertension, pain and falls. During record review on 10/11/23, it was noted that there was a medication profile dated 9/5/23. The record failed to document a medication reconciliation report. MR#3: The start of care (SOC) was dated 9/20/23, with diagnoses that included chronic obstructive pulmonary disease (COPD), oxygen dependence, and pain. During record review on 10/11/23, it was noted that there was a medication profile dated 9/20/23. The record failed to document a medication reconciliation report. During an interview on 10/11/23 at 3:45 p.m., the findings were reviewed and acknowledged by the administrator (ADM-1) and the clinical manager (CM-1).

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 appropriate interventions with objectively measurable goals specific to the individualized needs of the patient in 7 of 7 (P-1, 2, 3, 4, 5, 6, 7) records reviewed, resulting in the potential for poor patient outcomes and unmet care needs. Findings include: P-4: This 77-year-old patient was admitted to home care on 3/4/23 with a diagnosis of type 2 diabetes, osteoarthritis, and recent pacemaker insertion. During record review on 10/10/23 at 1:00 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, “patient will maintain prescribed diet compliance during the episode.” Additionally, the record failed to include goals related to the recent pacemaker insertion. P-5: This 66-year-old patient was admitted to home care on 9/22/23 with a diagnosis of bilateral osteoarthritis of the knees and chronic obstructive pulmonary disease (COPD). During record review on 10/11/23 at 10:30 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, “patient will verbalize an understanding of energy conserving measures by 10/28/23.” Another states, “patient will remain free from increased confusion during the episode.” P-6: This 82-year-old patient was admitted to home care on 8/30/23 with a diagnosis of hypertensive heart disease and congestive heart failure. During record review on 10/11/23 at 1:30 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, “patient will verbalize an understanding of energy conserving measures by 10/14/23.” Another states, “patient will remain free from increased confusion during the episode.” P-7: This 66-year-old patient was admitted to home care on 8/25/23 with a diagnosis of essential hypertension and chronic pain. During record review on 10/11/23 at 3:15 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, “patient will maintain adequate diet compliance during the episode.” Another states, “patient will remain free from increased confusion during the episode.” There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. These findings were reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/12/23 at 1:00 p.m. MR#1: The start of care (SOC) was dated 4/4/23, with diagnoses that included type 2 diabetes mellitus, and hypotension. During record review on 10/10/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, "The patient/caregiver will verbalize understanding of individualized emergency plan by 4/15/23." Another stated, "The patient/caregiver will verbalize understanding of proper diabetic foot care by 5/27/23." MR#2: The start of care (SOC) was dated 9/5/23, with diagnoses that included hypertension, pain and falls. During record review on 10/11/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, "The patient/caregiver will verbalize understanding of symptoms of cardiac complications and when to call 911 by 10/28/23." Another stated, "Patient will maintain prescribed diet compliance during the episode." MR#3: The start of care (SOC) was dated 9/20/23, with diagnoses that included chronic obstructive pulmonary disease (COPD), oxygen dependence, and pain. During record review on 10/11/23, it was noted that the goals on the POC were not measurable, for example, one goal stated, "The patient will verbalize an understanding of energy conserving measures by 10/28/23." Another stated, "The patient/caregiver will verbalize and demonstrate safe management of oxygen by 10/28/23." There was no evidence of how these goals could be objectively measured to determine progress toward meeting the goals. During an interview on 10/11/23 at 3:45 p.m., the findings were reviewed and acknowledged by the administrator (ADM-1) and the clinical manager (CM-1).

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 clinical record contained completed assessments and visit notes for 1 of 7 (P-6) records reviewed, resulting in a lack of information for the physician and all agency staff caring for the patient. Findings include: P-6: This 82-year-old patient was admitted to home care on 8/30/23 with a diagnosis of hypertensive heart disease and congestive heart failure. During record review on 10/11/23 at 1:30 p.m., it was noted that the initial RN assessment dated 8/30/23, did not contain an actual weight to accurately monitor potential worsening of congestive heart failure and on the visit dated 9/20/23, no weight was documented. Additionally, the initial RN assessment indicated there was edema (swelling) and documented as +2. No actual measurements were found in the medical record. The following two nursing visits dated 9/5/23 and 9/7/23, failed to include any documentation of edema. These finding were reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/12/23 at 1:00 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 2 of 2 (P-1, 4) discharge records reviewed, resulting in a lack of information to ensure continuity of care. Findings include: P-4: This 77-year-old patient was admitted to home care on 3/4/23 with a diagnosis of type 2 diabetes, osteoarthritis, and recent pacemaker insertion. During record review on 10/10/23 at 1:00 p.m., it was noted that the patient was discharged from agency services on 4/19/23. The discharge summary report bears a “Faxed” date indicating when the report was sent to the physician of 5/12/23 (23 days after discharge). This finding was reviewed and acknowledged by the administrator (ADM-1) and clinical manager (CM-1) during an interview on 10/12/23 at 1:00 p.m. MR#1: The start of care (SOC) was dated 4/4/23, with diagnoses that included type 2 diabetes mellitus, and hypotension. During record review on 10/10/23, it was noted that the patient was discharged from the agency on 4/25/23. The discharge summary/OASIS had a fax date of 5/11/23. 16 days after the patient was discharged. During an interview on 10/11/23 at 3:45 p.m., the findings were reviewed and acknowledged by the administrator (ADM-1) and the clinical manager (CM-1).

The following Condition and Standard level deficiencies were identified at a Medicare authorized complaint investigation (#62779), concurrent with the vaccine mandate protocol review conducted by the Michigan Department of Licensing and Regulatory Affairs on 12/13/22 through 12/14/22 at: Home Pro Care 27908 Orchard Lake Rd., Suite A Farmington Hills, MI 48334 At the conclusion of the investigation, the Agency was determined to be non-compliant with the following Condition of Participation: 42 CFR §484.70 Infection Control. The results of the Complaint investigation yielded the following: Allegation #1: Substantiated. Allegation #2: Substantiated. Allegation #3: Unsubstantiated. As a result of the Condition level noncompliance, the Agency is prohibited for 2 years from offering a Home Health Aide training and competency evaluation or a competency evaluation program as specified in 42 CFR §484.80(f)(3).

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 pertinent interventions, patient and family teaching and objectively measurable goals that addressed the patient's identified diagnoses and needs, for 1 (MR #1) of 2 records, from a total of 2 sampled records reviewed, resulting in the patient not receiving care specific to the identified needs and the potential for poor patient outcomes. Findings include: Policy: "Profession/Ancillary Care Plans" III-20, 9/29/14 stated, "An individualized plan of care shall be developed and implemented..., shall conform to the physician's plan of treatment..., shall be based on a systemic process of assessment, problem and need identification..." MR #1: The patient's start of care (SOC) was 10/16/21 with diagnoses that included Diabetes Mellitus. The plan of care (POC) ordered Physical Therapy and Skilled Nursing services to be provided. The clinical record review was conducted on 12/14/22 at 11:15 a.m. A doctor's note dated 10/6/21 documented, "80-year-old female homebound secondary to CHF (Congestive Heart Failure), poor gait, chronic pain, right knee replacement..., Brain tumor, recent diagnosis, benign tumor of cerebral meninges, has dizziness and syncope, fell 3x in a month due to syncope..." Upon further review of the clinical record, it was noted that the POC did not include the patient's recent diagnosis or any associated interventions, teaching or measurable goals that addressed the diagnosis of Brain Tumor. These findings were reviewed with and acknowledged by the Administrator and Clinical Manager during an interview on 12/14/22 at 12:40 p.m. The Administrator reported, "The diagnosis should have been added to the plan of care. It's a recent diagnosis. There should have been teaching added as well. I guess we only focused on the Face to Face and not the other Physician's documentation."

Infection prevention and control CFR(s): 484.70 Condition of Participation: Infection prevention and control. The HHA must maintain and document an infection control program which has as its goal the prevention and control of infections and communicable diseases. This CONDITION is not met as evidenced by: Based on record review and interview, the Agency failed to establish Vaccine protocol written policies and procedures that included (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have requested/been granted an exemption from the Covid-19 requirements; (x) Contingency plans for staff who are not fully vaccinated for Covid-19, and failed to ensure that all staff who were granted clinical privileges were vaccinated prior to the provision of care, resulting in the potential for the development and spread of the Covid-19 virus to staff and all 14 patients currently serviced by this Agency (G687). The cumulative effect of these systemic practices may result in the inability of the Home Health Agency to provide quality services in a safe environment for the Condition of Participation: §484.70 Infection Control.

COVID-19 Vaccination of Home Health Agency staff CFR(s): 484.70 (d)-(d)(3)(i-x) § 484.70 Condition of Participation: Infection Prevention and Control. (d) Standard: COVID-19 Vaccination of Home Health Agency staff. The home health agency (HHA) must develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19. For purposes of this section, staff are considered fully vaccinated if it has been 2 weeks or more since they completed a primary vaccination series for COVID-19. The completion of a primary vaccination series for COVID-19 is defined here as the administration of a single-dose vaccine, or the administration of all required doses of a multi-dose vaccine. (1) Regardless of clinical responsibility or patient contact, the policies and procedures must apply to the following HHA staff, who provide any care, treatment, or other services for the HHA and/or its patients: (i) HHA employees; (ii) Licensed practitioners; (iii) Students, trainees, and volunteers; and (iv) Individuals who provide care, treatment, or other services for the HHA and/or its patients, under contract or by other arrangement. (2) The policies and procedures of this section do not apply to the following HHA staff: (i) Staff who exclusively provide telehealth or telemedicine services outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section; and (ii) Staff who provide support services for the HHA that are performed exclusively outside of the settings where home health services are directly provided to patients and who do not have any direct contact with patients, families, and caregivers, and other staff specified in paragraph (d)(1) of this section. (3) The policies and procedures must include, at a minimum, the following components: (i) A process for ensuring all staff specified in paragraph (d)(1) of this section (except for those staff who have pending requests for, or who have been granted, exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations) have received, at a minimum, a single-dose COVID-19 vaccine, or the first dose of the primary vaccination series for a multi-dose COVID-19 vaccine prior to staff providing any care, treatment, or other services for the HHA and/or its patients; (ii) A process for ensuring that all staff specified in paragraph (d)(1) of this section are fully vaccinated for COVID-19, except for those staff who have been granted exemptions to the vaccination requirements of this section, or those staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations; (iii) A process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated for COVID-19; (iv) A process for tracking and securely documenting the COVID-19 vaccination status of all staff specified in paragraph (d)(1) of this section; (v) A process for tracking and securely documenting the COVID-19 vaccination status of any staff who have obtained any booster doses as recommended by the CDC; (vi) A process by which staff may request an exemption from the staff COVID-19 vaccination requirements based on an applicable Federal law; (vii) A process for tracking and securely documenting information provided by those staff who have requested, and for whom the HHA has granted, an exemption from the staff COVID-19 vaccination requirements; (viii) A process for ensuring that all documentation, which confirms recognized clinical contraindications to COVID-19 vaccines and which supports staff requests for medical exemptions from vaccination, has been signed and dated by a licensed practitioner, who is not the individual requesting the exemption, and who is acting within their respective scope of practice as defined by, and in accordance with, all applicable State and local laws, and for further ensuring that such documentation contains (A) All information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications; and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the HHA's COVID-19 vaccination requirements for staff based on the recognized clinical contraindications; (ix) A process for ensuring the tracking and secure documentation of the vaccination status of staff for whom COVID-19 vaccination must be temporarily delayed, as recommended by the CDC, due to clinical precautions and considerations, including, but not limited to, individuals with acute illness secondary to COVID-19, and individuals who received monoclonal antibodies or convalescent plasma for COVID-19 treatment; and (x) Contingency plans for staff who are not fully vaccinated for COVID-19. This STANDARD is not met as evidenced by: Based on record review and interview, the Agency failed to establish Vaccine protocol written policies and procedures that included (iii) implementation of additional precautions to mitigate the transmission and spread of Covid-19; (vii) a process for tracking/documenting information provided by staff who have requested/been granted an exemption from the Covid-19 requirements; (x) Contingency plans for staff who are not fully vaccinated for Covid-19, and failed to ensure that all staff who were granted clinical privileges were vaccinated prior to the provision of care, resulting in the potential for the development and spread of the Covid-19 virus to staff and all 14 patients currently serviced by this Agency. Findings include: Policy: (Untitled/undated) stated, "The Agency has established an [sic] COVID/influenza vaccination program for patient care staff, contract staff and licensed independent practitioners..., The Agency may provide the vaccinations and/or encourage patient care staff and contract staff to obtain vaccinations from their primary care providers or local health departments." On 12/14/22, upon review of the Agency's Vaccine policy, it was noted that the requirements of this section had not been met or included in the agency's Vaccine policy. There was no requirement of staff to be vaccinated, and no contingency plan put in to place for all staff who had not been vaccinated and/or who had been granted an exemption. There was no process put into place for tracking those individuals who had not been vaccinated. There was no process for the implementation of additional precautions for all staff who had not been vaccinated fully or in part. Additionally, of the 15 staff identified during the onsite survey, only 7 staff had been vaccinated. These findings were discussed with and acknowledged by the Administrator and Clinical Manager during an interview on 12/14/22 at 2:00 p.m.