Every finding on record at Mclaren Health Management Group

An unannounced Complaint survey (31976) and Focused Infection Control survey were conducted by the Michigan Department of Licensing and Regulatory Affairs on 10/29/21 at: McLaren Home Health 12900 Hall Road, Suite 200 Sterling Heights, MI 48313 For this survey, 10 discharge and 5 active records without home visits were reviewed, for a total of 15 records. The agency maintains one CMS approved (7/2/21) branch location at: 1411 3rd St., Suite C Port Huron, MI 48606 There were 13 allegations, with all allegations found to be unsubstantiated due to lack of sufficient evidence. A standard level citation (G-704) was issued unrelated to the complaint investigation. Please see CMS-2567 concerning complaint intake 31976. At the conclusion of the survey, the agency was found to be in compliance with the regulatory requirements at 42 CFR§484.70 Infection Control and 42 CFR §484.00 Home Health Agencies.

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 document review and interview, it was determined the Agency failed to ensure Skilled Nursing (SN) adequately assessed and monitored the needs of the patient in 1 (MR# 14) of 5 patients diagnosed with heart failure from a total sample of 15 records. Findings include: MR#14: The patient was admitted on 4/25/2021 with diagnoses which included diabetes, chronic kidney disease, pressure ulcer of left and right buttock, and congestive heart failure (CHF). The plan of care (POC) dated 4/25/21, ordered skilled nursing (SN) services at a frequency of 2W1 (twice a week for one week), 1W4, and 1Q2W4 (one every other week for four weeks). On 10/29/21, review of the start of care (SOC) comprehensive assessment (4/25/21) noted SN had documented the patient's weight as 235 pounds. Subsequent SN visits documented the patient's weight as: 5/14/21-238 pounds, 5/18/21-242 pounds with physician notification and medication change noted, 5/25/21-no weight entry, 6/7/21 (20 days from previous weight recording) was 257. No weight parameters to notify the physician were noted on the POC. During an interview with the Alternate Administrator (A-Adm#1) and Clinical Manager on 10/29/21, the findings were reviewed and acknowledged. Policy: "Ongoing Assessments" 2-022.1 (revised 5/21/2019) stated, "Using the standards of care identified by the organization, the clinician will reassess the patient for ongoing eligibility: Weight (once each week, if indicated by disease process). Re-assessments should focus on: A. Patient's response to care, B. Changes in patient condition." The Agency failed ensure SN had documented the patient's response concerning the new medication change noted on 5/18/21, failed to acquire the patient's weight on 6/25/21, and failed to incorporate an appropriate timeframe in which to assess and monitor the patient's weight based on the diagnosis of CHF.