Every finding on record at Mercy Hands Home Care, Inc.

From 2/23/21 through 2/25/21, a recertification and COVID-19 infection control survey was conducted by the Michigan Department of Licensing and Regulatory Affairs at: Mercy Hands Home Care, Inc. 20600 Eureka Rd., Suite 711 Taylor, MI 48180 This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

On 9/21/20, the Michigan Department of Licensing and Regulatory Affairs attempted to conduct a Recertification survey and a Focused Infection Control Covid-19 survey at: Mercy Hands Home Care, Inc. 20600 Eureka Rd., Suite 711 Taylor, MI 48180 On 9/21/20 at 9:30 a.m., the following observations were noted upon arrival at the agency address on record: The agency suite is located inside an office building, on the 7th floor. There was no answer to knocking at the suite door. The suite was dark. The phone number to Mercy Hands Home Care, Inc. at 734-285-3813 was called at 9:45 a.m. and a message left to call surveyor. Posted on outside of the suite door was a message stating, "To whom it may concern: To practice safety and minimize the exposure of Covid 19 (Coronavirus) the office of Mercy Hands Home Care will remain CLOSED until further notice. Our field operation will continue and we will be available via phone as needed. Call us at 734-556-4000. Please leave a voicemail if no answer. We assure you that we will return your call in the order it was received." The phone number 734-556-4000 was called at 9:45 a.m., a voice mail message was left requesting a return phone call. At 10:00 a.m., a second phone call was placed to the phone number on record (734-285-3813) for Mercy Hands Home Care, Inc. The phone call went straight to voice mail with identification as Mercy Hands Home Care, Inc. A voice mail message for a return phone call was left for the recipient. A return call has not been received. The surveys were not conducted as the agency is deemed non-operational. -------- From 2/23/21 through 2/25/21, a recertification and COVID-19 infection control survey was conducted by the Michigan Department of Licensing and Regulatory Affairs at: Mercy Hands Home Care, Inc. 20600 Eureka Rd., Suite 711 Taylor, MI 48180 This agency has no extension sites. For this survey 2 home visits (only 2 visits were available) with record reviews, 4 active records without a home visit and 2 discharged records were reviewed. 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.

HHA administrator contact information CFR(s): 484.50(a)(1)(ii) (ii) Contact information for the HHA administrator, including the administrator's name, business address, and business phone number in order to receive complaints. This ELEMENT is not met as evidenced by: Based on document review and interview, the Home Health Agency (HHA) failed to include contact information for the HHA's Administrator (Adm.-A) in the agency's Patient Admission/Orientation Packet, resulting in the potential for unaddressed patient concerns or complaints. Findings include: On 2/25/21 at 11:05 a.m., the HHA's Admission packet was reviewed. The packet included a consent form, admission agreement, Beneficiary notice and patient rights and responsibilities forms. Upon review, it was noted there was no name provided for Adm.-A. These findings were reviewed with Adm.-A on 2/25/21 at 1:50 p.m., Adm.-A responded, "We are having new folders made and the information is in them."

Contact info Federal/State-funded entities CFR(s): 484.50(c)(10)(i,ii,iii,iv,v) Be advised of the names, addresses, and telephone numbers of the following Federally-funded and state-funded entities that serve the area where the patient resides: (i) Agency on Aging (ii) Center for Independent Living (iii) Protection and Advocacy Agency, (iv) Aging and Disability Resource Center; and (v) Quality Improvement Organization. This ELEMENT is not met as evidenced by: Based on document review and interview, it was determined the home health agency failed to advise the patients of the names, addresses and telephone numbers of Federally-funded and State-funded entities that serve the area where the patient resides, resulting in the potential for patient needs being unmet. Findings include: During review of the agency's patient information folder on 2/25/21, no documentation was found that the information for Federally and State funded patient resource entities were provided to the patients. During an interview on 2/25/21 at 11:30 a.m., after a brief review of the patient information handbook, the administrator (Adm.-A) stated, "I will add those resources to the folder."

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 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 include objectively measurable goals specific to the needs of the patient for 7 of 8 (MR's # 1, 2, 4, 5, 6, 7, and 8) records reviewed, from a total of 8 sampled records reviewed, for a potential of patients not receiving care specific to their individual needs and poor patient outcomes, negatively affecting all patients serviced by the agency. Findings included: M.R. #4: This patient was admitted to the agency on 6/24/20 with the diagnoses of, "Type 2 Diabetes Mellitus with Diabetic Neuropathy, Essential Hypertension (HTN), Chronic Obstructive Pulmonary Disease (COPD) and Low Back Pain (LBP)." The Plan of Care (POC) ordered SN (skilled nurse) and PT (physical therapy) services. During a review of the Plan of Care on 2/24/2021, it was noted the goals were not individualized and not objectively measurable, examples include: "Patient will demonstrate proper use of assistive devices, patient will demonstrate return to stable cardiovascular status regarding HTN and verbalize improvement to symptoms by end of episode. Patient will maintain blood sugar within normal range by end of episode as evidence by reading within therapeutic range and hemoglobin A1C by end of episode." M.R. #5: This patient was admitted to the agency on 2/4/2021 with the diagnoses of, "Bilateral Primary Osteoarthritis of Hip, Pain in Right and Left Hip, Essential Hypertension and Abnormalities of Gait and Mobility." The Plan of Care ordered PT (physical therapy) services only. During a review of the Plan of Care on 2/24/2021, it was noted the goals were not individualized and not objectively measurable, examples include, "Pain free ADLs (activities of daily living) and IADLs independent in safe and functional transfer, safe and functional mobility with or without assistive device, Patient will demonstrate understanding of individual emergency preparedness plan.., Patient will attain optimal effectiveness of pain management regimen by 3 weeks.., Patient will demonstrate knowledge of pain medication and proper administration by 6 weeks, Patient will demonstrate ability to manage pain medication regimen by 6 weeks..., and Patient activity level will improve due to effective pain control by 6 weeks." M.R. #6: This patient was admitted to the agency on 2/10/2021 with the diagnoses of, Spondylosis with Radiculopathy-Lumbar Region, Anxiety Disorder, Pain in Right and Left Hip, Type 2 Diabetes Mellitus and Hypertensive Chronic Kidney Disease." The Plan of Care ordered PT (physical therapy) services. During a review of the Plan of Care on 2/25/2021, it was noted the goals were not individualized and not objectively measurable, examples include, "Pain free ADLs (activities of daily living) and IADLs, independent in safe functional transfer and functional ambulation with or without assistive device..., Patient activity level will improve due to effective pain control by 6 weeks..., Patient will demonstrate ability to manage pain medication regimen by 6 weeks..., Patient will be able to demonstrate pain relief measures to mitigate pain by 6 weeks..., and Patient will attain optimal effectiveness of pain management regimen by 3 weeks." M.R. #7: This patient was admitted to the agency on 1/21/21 with the diagnoses of, Inflammatory Spondylosis-Lumbar Region, Low Back Pain and Chronic Obstructive Pulmonary Disease (COPD)." The Plan of Care ordered PT (physical therapy) services only. During a review of the Plan of Care on 2/25/2021, it was noted the goals were not individualized and not objectively measurable, examples include, "Pain free ADLs (activities of daily living) and IADLs independent in safe and functional transfer, safe and functional mobility with or without wide base of Quad cane..., Patient will demonstrate safe gait stability with decreased risk for injury by 6 weeks..., Patient will improve bed mobility to independence to regain safe/ind (individual) functional bed mobility by 2 weeks..., Patient will improve bed mobility to minimum assistance to achieve safe/ind functional bed mobility by 2 weeks, Patient will demonstrate knowledge of pain medication and proper administration by 6 weeks, Patient will demonstrate ability to manage pain medication regimen by 6 weeks..., Patient will attain optimal effectiveness of pain management regimen by 3 weeks..., and Patient activity level will improve due to effective pain control by 6 weeks." M.R. 8: This patient was admitted to the agency on 10/8/20 with the diagnoses of, Acute Upper Respiratory Infection, Heart Failure and Chronic Pulmonary Obstructive Disease (COPD)." The Plan of Care ordered SN (skilled nurse) and PT (physical therapy) services. During a review of the Plan of Care on 2/25/2021, it was noted the goals were not individualized and not objectively measurable, examples include, the goals on the POC were documented as: "Patient/Caregiver will demonstrate knowledge of pain medication and proper administration by end of episode..., Patient/Caregiver will demonstrate ability to manage pain medication regimen by end of episode..., Patient's activity level will improve due to effective pain control by end of episode..., Patient will attain optimal effectiveness of pain management regimen by end of episode..., Patient will demonstrate return to stable respiratory status regarding COPD and verbalize improvement to symptoms with improved pulse oxygenation by end of episode..., and Patient will demonstrate return to stable cardiovascular status regarding CHF, HTN and verbalize improvement to symptoms by end of episode." There was no measurable definition of how this patient can demonstrate the pathophysiology and management of the respiratory and cardiac disease processes. MR#1: The start of care (SOC) was dated 6/23/2020, with diagnoses that included low back pain, type 2 diabetes mellitus and chronic obstructive pulmonary disease (COPD). During record review on 2/23/21, the goals on the plan of care (POC) were found to be no measurable, for example, one goal stated, "Patient and/or caregiver will verbalize signs and symptoms of cardiac complications, when to call physician, nurse or 911 by end of episode." Another stated, "Patient/caregiver will demonstrate knowledge of pain medication and proper administration by end of episode." MR #2: The SOC was dated 1/21/2021, with diagnoses that included hypertension (HTN), low back pain and type 2 diabetes mellitus. During record review on 2/24/21, the goals on the POC were found to be not measurable, for example, one goal stated, "Patient/caregiver will be able to verbalize signs and symptoms of cardiac complications, when to call physician, nurse or 911 by end of episode. Patient/caregiver will be able to demonstrate pain relief measures to mitigate pain by end of episode." There was no evidence of how these goals could be objectively measured to ascertain progress toward goals. During an interview on 2/25/21 at 1:00 p.m., the administrator (Adm.-A) agreed with the above findings.

Infection control CFR(s): 484.70(b)(1)(2) Standard: Control. The HHA must maintain a coordinated agency-wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases that is an integral part of the HHA's quality assessment and performance improvement (QAPI) program. The infection control program must include: (1) A method for identifying infectious and communicable disease problems; and (2) A plan for the appropriate actions that are expected to result in improvement and disease prevention. This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to maintain a program for the identification, prevention, control, and investigation of infectious and communicable diseases, that is a part of the Quality Assessment and Performance Improvement program, resulting in the potential for increased, untreated infections among the Agency's patient and staff population, for a potential to negatively impact all patients and staff. During an interview on 2/25/2021 at 9:45 AM, a request was submitted to review the infection control reports for the employees and the patients for 2018, 2019, and 2020. During the review of the "Patient Infection Control Binder" it was noted all infection control forms from 2016 to 2021 documented "zero patient infection," there were no documents presented for employee infections. When queried who was responsible for collecting the data, compiling, and analyzing the data and completing the annual report Administrator A (Adm.-A) replied, "I am. I get the information from the report generated from the computer." After a brief review of the "Unduplicated Census Report" dated 2/23/2020 to 2/23/2021 it was noted there were two patients with a diagnosis pertaining to infection: M.R. #7-Start of Care date was 1/21/2021, diagnosis-Unspecified Inflammatory Spondylopathy-Lumbar Region and M.R. #8-Start of Care date was 10/8/2020-Primrary Diagnosis was Acute Upper Respiratory Infection. There was no documented evidence data had been collected and had been monitored for these two patients on the 2020 and 2021 infection control reports. After a brief review of the information that is required for the infection control report Adm.-A stated, "I didn't know that information had to be included in the report."

Infection control education CFR(s): 484.70(c) Standard: Education. The HHA must provide infection control education to staff, patients, and caregiver(s). This STANDARD is not met as evidenced by: Based on record review and interview, the agency failed to provide education to all employees on the COVID-19 Pandemic Disease for 2020, for a potential of employees not being prepared to handle a pandemic disease, negatively impacting the safety of all patients serviced by the agency and all employees. Findings include: During an interview on 2/24/2021 at 2:30 PM a request was submitted to review the employee COVID-19 In-service training for 2020. The Administrator A (Adm.-A) submitted a binder titled, "Essential In-Service" with the following documents: TB (tuberculosis), HIV, Staph Infection, Patient Privacy, Need Stick, Safe Medical Device Act, Potentially Infectious Bodily Fluids and two pages on COVID-19. During a review of the binder it was noted there were no signature sheets to identify the employees that participated in the training, the time the in-services were performed and no documentation to identify the person that presented each in-service. It was queried if there was a signature sheet to identify the employees that participated in the COVID-19 in-service training Adm.-A replied, "No, I don't have a signature sheet or anything in writing to identify the staff that participated in the in-service. Sometimes we have meetings over the phone, so I didn't write it down." There was no documented evidence that an in-service had been provided to all employees to provide critical elements associated with the transmission of the COVID-19 disease.