Every finding on record at Michigan Home Rehabilitation, LLC

On 9/23/24 through 9/26/24, an Emergency Preparedness survey was conducted by the Michigan Department of Licensing and Regulatory Affairs. At the survey, Home Care Wellness was found to be in compliance with the requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs on 9/23/24 through 9/26/24 at: At Home Rehab 501 Baldwin Street, Ste. 203 Jenison, MI 49428 At the time of the survey, the Agency did not have any branch offices or subunits. For this survey, 3 home visits with record reviews, 1 active record without a home visit and 3 discharged records were reviewed for a total of 7 records reviewed. At the conclusion of the survey, the Agency was found to be out of compliance for the conditions of participation for home health agencies at: 42 CFR Part 484.

Health, psychosocial, functional, cognition CFR(s): 484.55(c)(1) Standard: Content of the comprehensive assessment. The comprehensive assessment must accurately reflect the patient's status, and must include, at a minimum, the following information: (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 resumption of care (ROC) comprehensive assessment accurately reflected the patient's current health status in 1 (P-7) of 1 record reviewed with a ROC, out of a total of 7 sampled records, resulting in incomplete clinical information and the potential for unmet care needs. Findings include: P-7: The start of care date for the patient was 3/29/24 with diagnoses which included chronic congestive heart failure, chronic kidney disease, bilateral knee osteoarthritis, and pressure ulcer of right hip-stage 2. On 9/25/24, record review noted P-7 was transferred (4/4/24 through 4/21/24) to sub-acute rehabilitation for failure to adequately participate in PT services. Review of the discharge summary from the rehabilitation facility documented the following concerning a new clinical finding: "skin tear Left wrist- cleanse the NS (normal saline) and cover with clean dressing." (sic) However, review of the ROC comprehensive assessment performed by skilled nursing (SN) on 4/22/24, found no evidence in the clinical record of SN acknowledging or updating the clinical status of the skin tear noted above. An interview was conducted with the Agency's Administrator (Adm. #1) on 9/26/24 at 11:25 AM. Adm. #1 reviewed and acknowledged the above finding and noted the nurse should have had assessment documentation regarding the status of the skin tear on the left wrist.

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 (POC) covered all pertinent interventions with reportable parameters, and objectively measurable goals specific to the needs of the patient for 1 (P-7) of 1 record reviewed with diagnosis of congestive heart failure, from a total sample of 7 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes. Findings include: P-7: The start of care (SOC) date for the patient was 3/29/24 with diagnoses which included chronic congestive heart failure, chronic kidney disease, bilateral knee osteoarthritis, and pressure ulcer of right hip-stage 2. On 9/25/24, review of P-7's POC found the primary diagnosis of diastolic congestive heart failure (CHF) had no safety parameters to monitor for CHF exacerbation (worsening). In addition, 9 of 9 skilled nursing goals were not written in measurable terms to track the progress made (or lack of) concerning how the patient responded to treatments provided. Examples include: "Pt's pain level will improve by Pt/Pcg (patient caregiver) verbalizing/demonstrating: Medication management for comfort and relief by using PRN (as needed) Tylenol, changing positions, using ice per preference by 5/10/24; Patient/Caregiver will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visits by 5/24/24." The above findings were reviewed and acknowledged by the Administrator (Adm. #1) during an interview on 9/26/24 at 11:25 AM. Adm. #1 stated this is not typical of the nurse's documentation in this case and did not meet Agency expectations as referenced in its policy below. Agency Policy: "Plan of Care" C-580 pg.264 (undated) stated, "The plan will be consistently reviewed to ensure that patient needs are met... All of the above items must always be addressed on the Plan of Care; ... p. Treatment goals." No language was found in the POC policy that goals must be measurable which is a CMS (Centers for Medicare and Medicaid Services) requirement.

Promptly alert relevant physician of changes CFR(s): 484.60(c)(1) The HHA must promptly alert the relevant physician(s) or allowed practitioner(s) to any changes in the patient's condition or needs that suggest that outcomes are not being achieved and/or that the plan of care should be altered. This ELEMENT is not met as evidenced by: Based on record review and interview, the Agency failed to ensure the physician was promptly notified of elevated blood pressure readings outside of the reportable parameters for 1 (P-5) of 7 records reviewed in total, resulting in the potential to negatively affect the health and well-being of this patient. Findings include: P-5: This 92-year-old patient was admitted to home care on 7/6/24 with diagnoses which included lower back pain, diabetes-type 2, and hypertensive chronic kidney disease. On 9/25/24, record review noted the Plan of Care (POC) effective 7/6/24, ordered the physician to be notified regarding the following parameters for the patient's blood pressure (BP): systolic > (greater) 140 or 90 or < 60. Further record review revealed the initial comprehensive assessment performed by physical therapy (PT) on 7/6/24, had documented P-5's BP as 158/112. The next visit (7/10/24) by PT had documented the patient's BP as 154/90. There was no documented evidence in the clinical record that the physician was promptly alerted as ordered concerning P-7's elevated BP readings above, which were outside of safety parameters noted in the patient's POC. These findings were reviewed with and acknowledged by the Administrator during an interview on 9/26/24 at 10:40 AM.

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 the needs of the patient were met when Physical Therapy (PT) had discharged the patient in a state of clinical decline in 1 (P-7) of 3 records reviewed with Agency discharge by PT services, from a total sample of 7 records reviewed, resulting in the patient being prematurely discharged without care needs and goals being met. Findings included: P-7: The start of care (SOC) date for the patient was 3/29/24 with diagnoses which included chronic congestive heart failure, chronic kidney disease, bilateral knee osteoarthritis, and pressure ulcer of right hip-stage 2. On 9/25/24, record review noted P-7 was transferred (4/4/24 through 4/21/24), to sub-acute rehabilitation for failure to adequately participate in PT services. PT services re-evaluated P-7 on 4/23/24, with a visit frequency of 2W5 (twice a week for 5 weeks). During review of the re-evaluation, no ambulation distance was noted, and PT services documented the following: "Even with lifted recliner, patient has difficulty getting up due to severity of OA/weakness in his knees and his height... Bed is too low, and patient is requiring 2-3 assist to get up." The patient's Plan of Care (POC) documented, "Will improve safety and independence during ambulation on even surfaces with 4WW (wheeled walker) and SBA (stand by assist) x 200 feet. Achieve by date: 05/24/2024 Start effective date: 04/23/2024." PT services documented on the next visit (4/26/24) that "Pt (patient) reports no c/o (compliant) of pain. Was walking really well yesterday but struggling more today. Chief c/o increased fatigue and weakness." Despite the noted difficulties of P-7 on 4/26/24, the documented ambulation was still 235 feet. During the third visit prior to Agency discharge, PT had documented on 5/17 24 that the patient's ambulation had decreased to 200 feet, despite an additional 5 PT visits after 4/26/24. On 5/21/24, PT documented that P-7's ambulation further decreased to 175 feet with 4 WW on even surfaces with SBA, and no adverse findings were found. The day of discharge (5/24/24), PT documented that P-7's gait was only "100 feet in home with 2WW mod (moderate); patient is slow and unable to come to full upright standing...". However, PT still discharged the patient from the Agency despite the significant clinical decline with "Goals Met" which was sent to the physician. No evidence was found in the medical record that the Agency or PT services had communicated to the physician P-7 was discharged from the Agency with functional goals not met. An interview was conducted with the Agency's Administrator (Adm. #1) on 9/26/24 at 11:25 AM. Adm. #1 reviewed and acknowledged the above findings and noted this did not meet Agency expectations or its policy referenced below. Agency Policy: "Coordination of Patient Services" C-360, pg. 202 (undated) stated, "The coordination of care is provided by all disciplines and included communication with physicians. Coordination of care means assuring that the patient needs are continually assessed, addressed in the Plan of Care, that care is delivered in a timely and effective manner, and that goals are achieved." The Agency failed to ensure the patient had progressed in ambulation to meet safety standards and goals established in the plan of care.

A survey for Emergency Preparedness was not conducted by the Michigan Department of Licensing and Regulatory Affairs, Bureau of Community and Health Systems during the recertification from 9/28/21 through 10/1/21 due to standard citations found in the recertification survey.

A Medicare recertification and Covid-19 infection control survey was conducted on 9/28/21 through 10/1/21 by the Michigan Department of Licensing and Regulatory Affairs at: At Home Rehab 501 Baldwin Street, Ste. 203 Jenison, MI 49428 At the time of the survey, the agency did not operate any branch offices or subunits. Clinical records reviewed for this survey included 4 records with home visits, and 6 records without home visits, for a total of 10 records reviewed. At the conclusion of the survey, the agency was found to be out of compliance at the standard level with the conditions of participation for Home Health Agency at: 42 CFR Part §484.00

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 conduct a patient-specific, comprehensive assessment that accurately reflected the patient's current health status based on a past medical history that included dates of onset, exacerbations, treatments and outcomes, baseline data, history of events leading to current home care needs and the referral date in 5 of 10 records reviewed (MR#s 1, 2, 3, 4, and 5), and failed to obtain current baseline data for the patient's diagnoses of diabetes and congestive heart failure in 2 of 10 records (MR#s 2 and 3), resulting in incomplete clinical information to aid in determining the needs of the patient and determining progress towards goals. Findings included: MR#1: The Start of Care (SOC) was dated 8/13/21. The Plan of Care (POC) identified diagnoses of Cholangitis and Calculus of Bile Duct. dementia, depressive disorder, and history of falls. Upon review of the Comprehensive Assessment dated 8/13/21, it was noted under "Past Medical History" the above diagnoses were all listed as well as hypothyroidism, memory impairment, skin lesion right side of forehead, choledocholithiasis, Gerd, and hip fracture. However, all past diagnoses documented the same date of onset of 8/13/21. There was no history of how long the patient had any of the above diseases/conditions, no dates of onset documented, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the home care referral, and no assessment of the patient's specific current home care needs. MR#2: The SOC was dated 9/10/21. The POC identified diagnoses of "hemiplegia following Cerebral Vascular Accident (CVA), memory deficit, vascular dementia, Chronic kidney disease (CKD) with heart failure (HF), Diabetes Type 2 (DM2), and Congestive Heart Failure (CHF). along with 14 additional diagnoses. Upon review of the Comprehensive Assessment dated 9/10/21, it was noted that all past diagnoses documented the same date of onset as 9/10/21. There was no history of how long the patient had any of the above diseases/conditions, no dates of onset documented, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the home care referral, and no assessment of the patient's specific current home care needs. In addition, there was no baseline data collected for the patient's weight or objective measurements of lower extremity edema to determine the status of the patient's Congestive Heart Failure to use as a measure for to determine the patient's CHF status for future assessments that may need to be reported to the physician. Also, the PT (Physical Therapist #5) failed to document in the Start of Care assessment the patient's normal blood sugar ranges to use as a baseline in determining the patient's diabetic status for future assessments. MR#3: The SOC was dated 9/1/21. The POC identified diagnoses of Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes Type 2 (DM2), Obesity, and History of Falls. Upon review of the Comprehensive Assessment dated 9/1/21, it was noted under "Past Medical History" that all dates of onset were dated 9/1/21. There was no history of how long the patient had any of the above diseases/conditions, no dates of onset documented, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. In addition, there was no baseline data collected for objective measurements of lower extremity edema to determine the status of the patient's Congestive Heart Failure or to use as a measure for future assessments that may need to be reported to the physician. Also, PT#5 failed to document in the Start of Care assessment the patient's normal blood sugar ranges to use as a baseline in determining the patient's diabetic status for future assessments. MR#4: The SOC was dated 3/20/21. The POC identified diagnoses of "Bilateral Osteoporosis, Congestive Heart Failure (CHF), dementia, Spinal Stenosis, dementia, and alcohol dependence. Upon review of the Comprehensive Assessment dated 3/20/21, it was noted that all past diagnoses documented the same date of onset as 3/20/21. There was no history of how long the patient had any of the above diseases/conditions, no dates of onset documented, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the home care referral, and no assessment of the patient's specific current home care needs. MR#5: The SOC was dated 3/27/21. The POC identified diagnoses of Diabetes type 2 with hyperglycemia and neuropathy (DM2), Bladder Obstruction, Hypertension (HTN), Coronary Artery Disease (CAD), dementia, and depression. Upon review of the Comprehensive Assessment dated 3/27/21, it was noted that all past diagnoses documented the same date of onset as 3/27/21. There was no history of how long the patient had any of the above diseases/conditions, no dates of onset documented, or when and how the diseases occurred. There was no history of the status of the above diseases including treatments for past medical problems and outcomes of those treatments. There was no documented evidence of an assessment of the events that led to the home care referral, and no assessment of the patient's specific current home care needs. These findings were reviewed and acknowledged during an interview on October 1, 2021 at 11:00 a.m. with the Administrator (ADM#1), and Clinical Manager (CM#2).

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 policy review, record review and interview, the agency failed to ensure the plan of care included patient specific objectively measurable goals and outcomes in 5 of a total of 10 sampled records reviewed (MR#s: 1, 2, 3, 4 and 5), and failed to include reportable parameters for physician notification of the patient's health status, resulting in difficulty determining the patient's progress toward the achievement of goals and when the physician should be notified. Findings included: MR#1: The Start of Care (SOC) was dated 8/13/21. The Plan of Care (POC) identified diagnoses of Cholangitis and Calculus of Bile Duct, dementia, depressive disorder, and history of falls. Upon review of the Plan of Care dated 8/13/21, it was noted the goals on the POC were not appropriate or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient will verbalize and demonstrate knowledge of and adherence with medications including dose, route, and schedule actions, interactions, and contraindications, side effects/symptoms to report and emergency management by 9/10/21." The goal is not appropriate for this patient diagnosed with dementia, nor are the goals objectively measurable to determine the patient's progress towards goals. MR#2: The SOC was dated 9/10/21. The POC identified diagnoses of "hemiplegia following Cerebral Vascular Accident (CVA), memory deficit, vascular dementia, Chronic Kidney Disease (CKD) with heart failure (HF), Diabetes Type 2 (DM2), and Congestive Heart Failure (CHF), along with 14 additional diagnoses. Upon review of the Plan of Care dated 8/13/21, it was noted the goals on the POC were not appropriate or objectively measurable to determine the patient's progress towards goals. Examples include: "Patient/Caregiver will verbalize/demonstrate effective Pressure Ulcer Prevention Management including: measures to prevent skin breakdown; pressure relief, incontinence care, nutrition, hydration by 11/5/21"; "Patient/Caregiver will verbalize/demonstrate knowledge of wound healing including symptoms to report, phases and time frames, importance of general health and nutrition to promote wound healing, and monitoring wound status and prevention of infection by 11/5/21." These goals are not appropriate for a patient diagnosed with memory deficit and vascular dementia, nor are these goals objectively measurable. In addition, the Plan of Care failed to include reportable parameters for weight gain and diabetic glucose monitoring to address patient's diagnoses of Congestive heart failure and Diabetes respectively. MR#3: The SOC was dated 9/1/21. The POC identified diagnoses of "Heart Failure (HF), Chronic Obstructive Pulmonary Disease (COPD), Diabetes Type 2 (DM2), Obesity, and History of Falls. Upon review of the Plan of Care dated 8/13/21, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards goals. Examples include: "Patient's pain level will improve by patient/patient caregiver verbalizing/demonstrating medication management for comfort and relief by 10/01/21." "Patient/Caregiver will verbalize/demonstrate effective Pressure Ulcer Prevention Management including measures to prevent skin breakdown; pressure relief, incontinence care, nutrition." These goals are not objectively measurable to determine the patient's progress towards achievement of goals. MR#4: The SOC was dated 3/20/21. The POC identified diagnoses of "Bilateral Osteoporosis, Congestive Heart Failure (CHF), dementia, Spinal Stenosis, and alcohol dependence. Upon review of the Plan of Care dated 8/13/21, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards goals. Examples include: "Patient/Caregiver will verbalize/demonstrate understanding of symptom management, resource utilization and medication management to reduce unplanned hospital or emergency department visit by 5/1/21." The goals are not objectively measurable for a patient diagnosed with dementia. MR#5: The SOC was dated 3/27/21. The POC identified diagnoses of Diabetes type 2 with hyperglycemia and neuropathy (DM2), Bladder Obstruction, Hypertension (HTN), Coronary Artery Disease (CAD), dementia, and depression. Upon review of the Plan of Care dated 8/13/21, it was noted the goals on the POC were not objectively measurable to determine the patient's progress towards goals. Examples include: "Patient/Patient Caregiver will verbalize/demonstrate knowledge of disease management for Diabetes type 2 by recognizing signs/symptoms of complications and symptoms to report, emergency management by 4/23/21. These goals are not objectively measurable. These findings were reviewed and acknowledged during an interview on October 1, 2021 at 11:00 a.m. with the Administrator (ADM#1), and Clinical Manager (CM#2).