Every finding on record at North Oakland Home Health Care

On 1/14/2021 through 1/21/2021, the Michigan Department of Licensing and Regulatory Affairs conducted a recertification survey investigation at North Oakland Home Health Care. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

The following standard level deficiencies were noted during the Medicare recertification survey conducted by the Michigan Department of Licensing and Regulatory Affairs on 1/14/2021 through 1/21/2021 at: North Oakland Home Health Care 7736 Ortonville Road Suite B Clarkston, Michigan 48348 At 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 7 records without home visits for a total of 10 records reviewed.

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 document review and interview, the agency failed to ensure the comprehensive assessment included a review of all medications to identify any potential adverse effects and drug reactions for 4 of 5 (MR's #2, 3, 4, and 10) records reviewed which included major and/or duplicative drug therapies, and failed to ensure a registered nurse performed a review of the patient's medication list in which therapy only services were ordered in 1 of 1 record (MR#1) reviewed, from a total sample of 10 records, resulting in the potential for harmful medication effects for all 397 patients serviced by this agency in the last 12 months. Findings include: **Agency Policy: "MEDICATION POLICY" (Rev. 1/00) stated, "The R.N. reviews all medications to identify possible ineffective therapy or adverse reactions, significant side effects, drug allergies and/or contraindicated medication and promptly reports any problems to the physician." MR#1: The Start of Care (SOC) was dated 1/6/2021 with identified diagnoses of right total knee replacement, osteoarthritis, and hypertension. The plan of care (POC) dated 1/6/2021 ordered one discipline, physical therapy (PT) to evaluate and treat the patient. During review of the clinical record on 1/14/21, it was documented that the patient's medication review at the SOC was performed by PT#1. No evidence of a subsequent review by a registered nurse (RN) was found in the medical record. During an interview on 1/15/21 at 10:20 AM., the clinical director (CD#1) confirmed the above finding during a joint review of the clinical record with the surveyor. The agency failed to provide evidence an RN had reviewed the patient's medication list at the SOC as stipulated by agency policy. MR#2: The SOC was dated 12/18/2020 with identified diagnoses of chronic obstructive pulmonary disease, cellulitis of right and lower limbs, and heart disease with failure. During review of the clinical record on 1/14/2021, the medication reconciliation completed by skilled nursing (SN) documented the following: 2 major interactions (most severe) and 1 duplicative drug therapy. However, when the patient's 24 prescribed medications were then entered "Drugs.com" (online medication interaction checker), 4 major drug interactions and 5 duplicative drug therapies were revealed. No evidence was found that the physician was made aware of these additional findings. CD#1 acknowledged and agreed with the findings during an interview on 1/15/21 at 10:40 AM. CD#1 stated, "I surprised our system isn't catching these, especially all the duplicative drug therapies." MR#3: The SOC was dated 1/9/2021 with identified diagnoses of radiculopathy (pinched nerve pain), syringomyelia and syringobulbia (fluid filled cyst within the spinal cord and brainstem), and long-term use of opiates (pain control). During review of the patient's SOC comprehensive assessment on 1/15/2021 completed by SN, drug review section M2001 documented, "no issues found during review". A separate narrative found within the SOC assessment documented the physician was notified of 2 major drug interactions with no duplicative drug therapies. When the patient's 14 prescribed medications were entered "Drugs.com", 5 major drug interactions and 3 duplicative drug therapies were noted. No evidence was found that the physician was made aware of the additional findings. MR#4: The SOC was dated 12/18/2020 with identified diagnoses of heart disease with heart attack, hypertension, and diabetes-type 2. On 1/15/2021, review of the patient's SOC comprehensive assessment (12/18/20) performed by SN, drug review section M2001 documented, "no issues found during review". When the patient's 12 prescribed medications were entered "Drugs.com", 1 major drug interaction and 3 duplicative drug therapies were noted. During an interview on 1/15/2021 at 11:40 AM, CD#1 confirmed the above finding and stated, "I don't see anywhere in the record where the physician was notified." MR#10: The SOC was dated 6/20/2020 with identified diagnoses of lower left leg wound care, and long term non-steroidal and opiate pain control use. During review of the clinical record on 1/21/2021, the medication reconciliation completed by SN documented the following: 1 major interactions (most severe) and no duplicative drug therapies. However, when the patient's 14 prescribed medications were then entered "Drugs.com", 2 major drug interactions and 2 duplicative drug therapies were noted. No evidence was found that the physician was made aware of these additional findings. CD#1 acknowledged and agreed with the above findings during an interview on 1/21/21 at 12:05 PM. The agency failed to ensure that a comprehensive review of medications at the start of care identified all potential adverse drug reactions in which to notify the physician was performed.

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 document review and interview, the agency failed to ensure the plan of care included objectively measurable goals specific to the needs of the patient under skilled nursing, for 8 records (MR#s 2, 3, 4, 5, 6, 8, 9, and 10) from a total sample of 10 records reviewed, resulting in patients not receiving care specific to their individual needs and the potential for poor patient outcomes for the 397 patients serviced in the last 12 months. Findings included: MR#2: The Start of Care (SOC) was dated 12/18/2020 with identified diagnoses of chronic obstructive pulmonary disease, cellulitis of right and lower limbs, and heart disease with failure. The plan of care (POC) ordered skilled nursing (SN) visit frequencies of 1W5 (once a week for 5 weeks). Review of the POC on 1/14/21 noted that 14 of 14 listed goals by SN were not objectively measurable. Examples included: "Patient will demonstrate improvement in dyspnea as evidenced by Report within Weeks 4"; "Rn will teach Pt (patient) wound care management will demonstrate ability to change dressings and provide ordered wound care by cert period" (sic); "Infection control standards maintained by RN as taught by RN." These goals were not objectively measurable. MR#3: The SOC was dated 1/9/2021 with identified diagnoses of radiculopathy (pinched nerve pain), syringomyelia and syringobulbia (fluid filled cyst within the spinal cord and brainstem), and long-term use of opiates (pain control). The POC ordered SN visit frequencies of 1W2. Review of the POC on 1/15/21 noted that 10 of 11 listed goals by SN were not objectively measurable. Examples included: "Patient will demonstrate improvement in dyspnea as evidenced by improvement within cert period"; "Patient will demonstrate effective self-care management and who to call for questions, changes, concerns within Weeks 2." These goals were not objectively measurable, nor individualized to meet the patient's specific needs. MR#4: The SOC was dated 12/18/2020 with identified diagnoses of heart disease with heart attack, hypertension, and diabetes-type 2. The POC ordered SN visit frequencies of 1W1, 2W2, and 1W6. Review of the POC on 1/20/21 noted that 15 of 16 listed goals by SN were not objectively measurable. Examples included: "Patient will demonstrate improvement in dyspnea as evidenced by Report within Weeks 9"; "pt to demonstrate stabilization in transferring/ambulation be end of care." (sic) These goals were not objectively measurable, nor individualized to meet the patient's specific needs. MR#5: The SOC was dated 1/5/2021 with identified diagnoses of spinal stenosis (abnormal narrowing of the spinal canal), hypertension, and repeated falls. The POC ordered SN visit frequencies of 1W3. Review of the POC on 1/20/21 noted that 6 of 6 listed goals by SN were not objectively measurable. Examples included: "Patient will demonstrate improvement in dyspnea as evidenced by Report within 3 weeks"; "Patient will demonstrate effective self-care management and who to call for questions, changes, concerns within Week 4." MR#6: The SOC was dated 12/30/2020 with identified diagnoses of primary adrenocortical insufficiency (low hormone production from the adrenal glands), hypertension, and diabetes-type 2. The POC ordered SN visit frequencies of 1W4. Review of the POC on 1/20/21 noted that 9 of 10 listed goals by SN were not objectively measurable. Examples included: "Patient will demonstrate improvement/stabilization in cognitive functioning as evidenced by INTERACTIONS WITH PT within DURATION OF CARE" (sic); "pt will demonstrate effective self-care management and who to call for questions, changes, concerns within duration of care"; "Patient will demonstrate improved ambulation/locomotion as demonstrated by OBSERVATION OF PT with DURATION OF CARE." (sic) MR#8: The SOC was dated 6/20/2020 with identified diagnoses of lower left leg wound care, and long term non-steroidal and opiate pain control use. The POC ordered SN visit frequencies of 1W1, and 2W5. Review of the POC on 1/21/21 noted that 14 of 15 listed goals by SN were not objectively measurable. Examples included: "Patient will demonstrate effective self-care management and who to call for questions, changes, concerns within 2 weeks"; "Patient will achieve adequate skin integrity through use of dressing and monitoring within normal limits for patient to prevent skin breakdown 6 weeks" The SN failed to include individualized, measurable goals that would measure the progress made in meeting the patient's health care needs. MR#9: The SOC was dated 1/4/2020 with identified diagnoses of heart failure, chronic kidney disease, morbid obesity, and diabetes-type 2. The POC ordered SN visit frequencies of 1W1, and 2W4. Review of the POC on 1/21/21 noted that 19 of 20 listed goals by SN were not objectively measurable. Examples included: "pt, cg (caregiver) will adhere to/demonstrate compliance with multiple medication regimens as evidenced by V/U (verbal understanding) within cert"; "Patient will demonstrate improvement in dyspnea as evidenced by pt observation within cert." MR#10: The SOC was dated 6/20/2020 with identified diagnoses of lower left leg wound care, and long term non-steroidal and opiate pain control use. The POC ordered SN visit frequencies of 1W1, and 2W5. Review of the POC on 1/21/21 noted that 12 of 12 listed goals by SN were not objectively measurable. Examples included: "Patient will state pain at 0/10 on 0-10 scale by 4 weeks"; "Patient will demonstrate improvement in dyspnea as evidenced by observation within 4 weeks"; "Family and Patient will demonstrate knowledge of disease process, treatment goals, and self-care management as evidenced by verbalization and observation within 4 weeks." During an interview on 1/21/2021 at 11:50 AM, the clinical director acknowledged the above findings and stated, "We'll make the goals more measurable, that way we can track the progress made better." The agency failed to ensure that SN included individualized, measurable goals that would ascertain the progress towards meeting the patient's health care needs.

Ensures qualified pre-designated person CFR(s): 484.105(b)(2) When the administrator is not available, a qualified, pre-designated person, who is authorized in writing by the administrator and the governing body, assumes the same responsibilities and obligations as the administrator. The pre-designated person may be the clinical manager as described in paragraph (c) of this section. This ELEMENT is not met as evidenced by: Based on interview, the Agency failed to ensure a qualified alternate, was authorized in writing by the Administrator and the governing body, to function in the Administrator's absence, resulting in the potential for uncoordinated Agency functions. Findings include: On 1/14/2021 at 09:50 AM, the Entrance Conference was conducted. The Clinical Director (CD #1) was queried who the Alternate Administrator was. CD#1 replied, "I'm the alternate administrator." CD #1 was then asked if this role was formalized in writing. CD#1 stated, "No, it is not." A follow up interview on 1/14/21 at 13:30 PM with the Administrator (Adm #1) confirmed the above finding. Adm #1 stated, "I will write up an agreement and get it taken care of." The Agency failed to ensure a qualified alternate had been appointed by the Governing Board to act in the absence of the Administrator.