Every finding on record at Horizon Home Care

A Medicare authorized Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/22/24 at Horizon Home Care, 1001 Giesau Drive, Ontonagon, MI 49953. At the conclusion of the survey, the agency was determined to be in compliance with the Conditions of Participation at 42 CFR 484.102.

A Medicare recertification survey and complaint investigation for intake # MI0070672 was conducted by the Michigan Department of Licensing and Regulatory Affairs from 10/22/24 through 10/23/24 at: Horizon Home Care 1001 Giesau Drive Ontonagon, MI 49953 This agency has no branches. Clinical records reviewed for this survey included 3 records with home visits, 2 active records without home visits, and 2 discharged records. 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.

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 contained patient specific orders, individualized to the patient's identified needs, and covered all pertinent interventions with reportable parameters for 7 (P-1, 2, 3, 4, 5, 6, 7) of 7 records reviewed, resulting in patients not receiving care specific to their needs and the potential for poor patient outcomes. Findings included: **Agency Policy: "Care Planning, Coordination of Services and Quality of Care – 5002," (Effective 5/20). The policy states, "Policy: Patients are accepted for treatment on the reasonable expectation that an HHA can meet the patient’s medical, nursing, rehabilitative, and social needs in his or her place of residence… The individualized plan of care must specify the care and services necessary to meet the patient-specific needs as identified in the comprehensive assessment… The individualized plan of care must include the following: …Patient specific interventions…" P-5: The Start of Care (SOC) was dated 10/10/24. The Plan of Care (POC) identified diagnoses of Myelopathy Cervical Region, Hypertension and Weakness. During record review on 10/23/24, it was noted that the POC stated, “Orders For Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” 2 consecutive vital signs out of range could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-6: The Start of Care (SOC) was dated 10/9/24. The Plan of Care (POC) identified diagnoses of Perforation of Intestine and Hypertension. During record review on 10/22/24, it was noted that the POC stated, “Orders For Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” 2 consecutive vital signs out of range could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-7: The Start of Care (SOC) was dated 9/25/24. The Plan of Care (POC) identified diagnoses of Rhabdomyolysis, Cervical Disc Degeneration and Hypertension. During record review on 10/22/24, it was noted that the POC stated, “Orders For Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” 2 consecutive vital signs out of range could potentially lead to poor patient outcomes related to timeliness in urgent care needs. These findings were reviewed with and acknowledged by the Adm-1 (Administrator) during an interview on 10/23/24 at 1:00 pm. P-1: The Start of Care (SOC) was dated 6/8/24. The Plan of Care (POC) identified diagnoses of dislocation of right ankle joint, hypo-osmolality, and hypertension. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-2: The SOC was dated 7/3/24. The POC identified diagnoses of polymyalgia rheumatica, weakness, and congestive heart failure. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-3: The SOC was dated 9/12/24. The POC identified diagnoses of dehydration, hypokalemia, and weakness. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. P-4: The SOC was dated 1/4/24. The POC identified diagnoses of congestive heart failure, monoclonal gammopathy, and atrial fibrillation. During record review on 10/22/24, it was noted that the POC stated, “Orders for Discipline and Treatment: Notify Physician of 2 consecutive vital sign parameters out of range...” Two consecutive out of range vital signs could potentially lead to poor patient outcomes related to timeliness in urgent care needs. The findings were reviewed with and acknowledged by the administrator (Adm-1) during an interview on 10/23/24 at 1:30 p.m.

On 10/19/2021 through 10/22/2021, an Emergency Preparedness Survey was conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Community and Health Systems. At the conclusion of the survey, Horizon Home Care was found in substantial compliance with the requirements for participation in Medicare/Medicaid at 42 CFR 484.102, Emergency Preparedness.

The following standard level citations were identified by the Michigan Department of Licensing and Regulatory Affairs during a Medicare authorized recertification survey along with a COVID-19 Focused Infection Control survey on 10/19/2021 through 10/22/2021at: : Horizon Home Care 1001 Giesau Dr Ontonagon, MI 49953At the time of the survey, the agency did not operate any branch offices.Clinical records reviewed for this survey: 3 records with home visits and 4 records without home visits for a total of 7 records reviewed.At the conclusion of the survey the agency was found in compliance with 42 CFR §484 conditions of participation for Home Health Agencies.

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, and safety precautions in 1 of 7 records reviewed (MR #6), and failed to have objectively measurable goals in 7 of 7 (MR#s 1, 2, 3, 4, 5, 6, and 7) records reviewed out of a total of 7 records reviewed, resulting in the potential for poor patient outcomes for all 44 patients currently serviced by this Agency. Findings included: MR #6: The patient was admitted on 6/22/2021, which included diagnoses of auto-immune hepatitis, cirrhosis of liver, hyperkalemia (elevated blood potassium level), atrial fibrillation, and hypertension. The plan of care (POC) ordered skilled nursing (SN) visit frequencies of 2W3 (twice a week for three weeks), and 1W6. During review of the referral for home care on 10/21/21, the following patient medical history was noted: "... status post mastectomy and reconstruction of the left breast for cancer (undated). Review of the initial comprehensive assessment also documented a history of breast cancer (twice) with axillary lymphadenectomy. No evidence of interventions or safety precautions were found in the patient's POC that stipulated no blood pressures were to be taken on the affected surgical side of the mastectomy. In addition, 10 of 10 listed goals listed in the POC by SN were not objectively measurable for assessing patient improvement. Examples included: "Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection during episode of care; Patient will demonstrate return to stable gastrointestinal status regarding bleeding Hemorrhoids' and verbalize improvement with same by 7/22/21." The above findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 10/22/21 at 9:15 AM. Adm #1 stated it was an agency expectation for staff to avoid taking blood pressures on the affected surgical side of a mastectomy. MR #1: The patient was admitted on 8/23/2021, which included diagnoses of pressure ulcer of left heel-stage 2, left femur fracture, congestive heart failure, and atrial fibrillation. The plan of care (POC) ordered skilled nursing (SN) visit frequencies of 2WK9 (twice a week for nine weeks), and 3 PRN (as needed) visits for additional wound care. Review of the POC on 10/20/21 noted that 10 of 10 listed goals by SN were not objectively measurable for assessing patient improvement. Examples included: "Patient will achieve optimal left heel stage 2 wound healing without further s/s (signs and symptoms) of infection or complications by end of cert. period; Patient will receive safe and effective personal care during this episode of care; Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection during episode of care." MR #2: The patient's start of care (SOC) was 10/17/21 with diagnoses which included diabetes-type 2, major depressive disorder, and heart failure. The POC ordered SN visit frequencies of 3W1, 2W3, and 1W5. Review of the POC on 10/20/21 noted that 13 of 13 listed goals by SN were not objectively measurable. Examples included: "Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection during episode of care; Patient/Caregiver will verbalize understanding of potential complications of co-morbidities as related to primary Dx (diagnosis) by end of episode; By discharge the patient will report an increase in sense of control over their current situation." MR #3: The patient was admitted on 9/16/21 with diagnoses that included combined systolic and diastolic heart failure, chronic kidney disease, hypertension, asthma, and diabetes-type 2. The POC ordered SN visit frequencies of 2W3 and 1W6. Review of the POC on 10/20/21 noted that 11 of 11 listed goals by SN were not objectively measurable. Examples included: "Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection during episode of care; Patient will receive safe and effective personal care during this episode of care; Pt/cg will verbalize understanding of Coreg (heart medication) hold parameters by 10/21/21." MR#4: The SOC was dated 8/1/21, which included diagnoses of pressure ulcer of left knee-stage 3, diabetes-type 1 with neuropathy, and below the left knee amputation. The POC ordered SN visit frequencies of 3W2, 2W3, and 1W4. Review of the POC on 10/21/21 noted that 11 of 11 listed goals by SN were not objectively measurable. Examples included: "Patient and caregiver will be able to identify fall risk factors by 8/15/21; Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection during episode of care; Patient will attain optimal effectiveness of pain management regimen by 8/27/21." MR#5: The patient's SOC date was 10/1/19, which included diagnoses of chronic obstructive pulmonary disease, hypertension, and chronic systolic congestive heart failure. The POC ordered SN visit frequencies of 2W2, 1W1, and 6 PRN visits as needed visits for heart, pain, and medication complications. Review of the POC on 10/21/21 noted that 6 of 6 listed goals by SN were not objectively measurable. Examples included: "Patient will be able to demonstrate pain relief measures to mitigate pain within the next 4 weeks, 7/1/19; Patient will attain optimal effectiveness of pain management regimen within next 4 weeks, 7/1/19." MR#7: The patient was admitted on 1/15/21, with diagnoses which included Meniere's disease-bilateral (disorder of the inner ear), heart failure, and hypertension. The POC ordered SN visit frequencies of 2W3, and 1W6. Review of the POC on 10/21/21 noted that 9 of 9 listed goals by SN were not objectively measurable. Examples included: "Patient/Caregiver will verbalize understanding of potential complications of co-morbidities as related to primary Dx by end of episode; Patient will receive safe and effective personal care during this episode of care; Patient/caregiver will demonstrate steps to protect oneself and others from COVID-19 infection over cert period." The Agency failed to ensure the listed goals by SN were written in measurable, individualized terms to meet the patient's specific needs, and failed to incorporate preventative safety measures/interventions when warranted for a status post mastectomy patient.

Responsibilities of skilled professionals CFR(s): 484.75(b) Standard: Responsibilities of skilled professionals. Skilled professionals must assume responsibility for, but not be restricted to, the following: This STANDARD is not met as evidenced by: Based on record review, and interview, the Agency failed to ensure physical therapy (PT) services adequately assessed and monitored the needs of patients in 5 of 5 records reviewed with PT services (MR's #1, 2, 3, 6, and 7) from a total sample of 7 records reviewed, resulting in the potential for unidentified care needs and poor outcomes. Findings included: MR #1: The patient was admitted on 8/23/2021, which included diagnoses of pressure ulcer of left heel-stage 2, left femur fracture, congestive heart failure, and atrial fibrillation. The plan of care (POC) ordered PT services with a visit frequency of 1W1 and 2W4 (twice a week times four weeks). On 10/20/21, review of the clinical record noted the PT evaluation, under "Vital Signs" was documented as "N/A" (not applicable). All PT visit notes in the medical record were reviewed; no evidence that baseline assessments concerning the patient's vitals (blood pressure, heart rate, respirations, temperature, and oxygen levels) were ever obtained despite the noted cardiac diagnoses listed above. All entries were documented as "N/A" throughout the certification period. In addition, the patient was prescribed three blood pressure medications throughout the certification period. MR #2: The patient's start of care (SOC) was 10/17/21 with diagnoses which included diabetes-type 2, major depressive disorder, and heart failure. The POC ordered PT services with a visit frequency of 1W1 and 2W4. On 10/20/21, review of the clinical record noted the PT evaluation, under "Vital Signs" was documented as "N/A". All PT visit notes in the medical record were reviewed; no evidence that baseline assessments listed above were obtained prior or after working with therapy services. In addition to heart failure, the patient had a recent hospitalization on 8/23/21. The hospital discharge summary documented the following: "She (MR #2) was hypertensive during the visit. On several occasions I (physician) gave her clonidine (blood pressure medication) 0.1 mg. Will have her follow closely with outpatient to monitor her blood sugars and hypertension." Hospital discharge vital signs on 8/23/21 documented the patient's blood pressure as 199/86. All vital sign entries by PT services were entered as "N/A" throughout the certification period. Further, the patient was prescribed three blood pressure medications throughout the certification period. MR #3: The patient was admitted on 9/16/21 with diagnoses that included combined systolic and diastolic heart failure, chronic kidney disease, hypertension, asthma, and diabetes-type 2. The patient was hospitalized 8/24/21 through 9/3/21 and transferred to in-patient rehab on 9/3/21. The initial comprehensive assessment performed by SN (9/16/21) documented the following narrative pertaining to the patient ER visit on 8/24/21: "Pt (required 2.5 L per NC (nasal canula) to maintain O2 sats greater than 95%... found to have significant increase in creatinine, from 4.7-7.6 (critical level). Pt was started on dialysis. Permanent catheter placed 8/27/21. Evaluated by Cardiology who did recommend Coronary angiography. Found to have multi-vessel CAD (coronary artery disease), repeat Cardiac Catherization with stent placement performed 8/30/21." The patient was noted as having two blood pressure medications which were prescribed throughout the certification period. The POC ordered PT services with a visit frequency of 1W1 (evaluation). The POC documentation also noted under "Medical Necessity" for home care as being, "Patient with unstable cardiac status: prescribed changes to current plan of care due to need for CHF (congestive heart failure) management requiring skilled assessment..." On 10/20/21, record review noted the PT evaluation, under "Vital Signs" was documented as "N/A". No evidence that baseline assessments concerning the patient's vitals (blood pressure, heart rate, respirations, temperature, and oxygen levels) were obtained despite the above clinical findings. MR #6: The patient was admitted on 6/22/2021, which included diagnoses of auto-immune hepatitis, cirrhosis of liver, hyperkalemia (elevated blood potassium level), atrial fibrillation, and hypertension. The POC ordered PT services with a visit frequency of 1W1 and 2W4. On 10/21/21, review of the clinical record noted the PT evaluation, under "Vital Signs" was documented as "N/A". All PT visit notes in the medical record were reviewed; no evidence that baseline assessments concerning the patient's vitals were obtained despite the noted cardiac diagnoses listed above and being prescribed 4 blood pressure medications. MR#7: The patient was admitted on 1/15/21, with diagnoses which included Meniere's disease-bilateral (disorder of the inner ear), heart failure, and hypertension. The patient was hospitalized on 1/12/21 through 1/14/21 for dizziness, nausea, and dry heaving. The hospital discharge summary documented, "She (patient) was mildly bradycardic overnight with rates as low as 48 bpm (beats per minute)." The POC ordered PT services with a visit frequency of 1W1 and 2W4. On 10/21/21, review of the clinical record noted the PT evaluation, under "Vital Signs" was documented as "N/A". All PT visit notes in the medical record were reviewed; no evidence that baseline assessments concerning the patient's vitals were obtained despite the noted cardiac diagnoses listed above, hospital findings, and being prescribed 3 blood pressure medications. The above findings were reviewed and acknowledged by the Administrator (Adm #1) during an interview on 10/22/21 at 9:35 AM. Adm #1 stated, "I can't argue with this, we'll get this fixed immediately."