Every finding on record at North Woods Home Nursing

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/22/23 through 8/25/23 at: North Woods Home Care and Hospice 226 South Cedar Street Manistique, MI 49854 This agency has 3 extension sites located at: 129 E Superior St. Munising, MI 49862. 500 W. McMillan Newberry, MI 49868. 517 Ludington St. Escanaba, MI 49829. This was a standard survey. The requirements for participation in Medicare at 42 CFR 484.102 Emergency Preparedness were not reviewed.

A Medicare recertification survey was conducted by the Michigan Department of Licensing and Regulatory Affairs from 8/22/23 through 8/25/23 at: North Woods Home Care and Hospice 226 South Cedar Street Manistique, MI 49854 This agency has 3 extension sites located at: 129 E Superior St. Munising, MI 49862. 500 W. McMillan Newberry, MI 49868. 517 Ludington St. Escanaba, MI 49829. For this survey, 7 home visits with record reviews, 5 active records without a home visit, and 5 discharged records were reviewed (total of 17 records 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.

5 calendar days after start of care CFR(s): 484.55(b)(1) The comprehensive assessment must be completed in a timely manner, consistent with the patient's immediate needs, but no later than 5 calendar days after the start of care. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure the initial comprehensive assessment was completed no later than 5 calendar days after the start of care in 1 (Patient #16) of 17 records reviewed, resulting in the potential for unidentified patient needs. Findings include: P-16: This 84-year-old patient was admitted to home care for skilled nursing and physical therapy services on 8/18/23 after a hospitalization for hyponatremia (low sodium in the blood) and frequent falls. During record review on 8/23/23, it was determined the initial referral on 8/16/23 requested evaluation by skilled nursing and physical therapy. The start of care/initial assessment was completed by the nurse on 8/18/23. The Clinical Manager (Staff B) was queried during the entrance interview on 8/22/23 at 3:35 p.m. regarding the timeline to complete evaluations of other disciplines ordered. Staff B reported that these are expected to be completed within 5 days of the start of care. As of 8/23/23, there had not been an evaluation done by the physical therapist. Upon arrival to a survey home visit with skilled nursing for this patient on 8/23/23, the patient's daughter stated she had not heard from physical therapy on when they would be out to evaluate the patient. She also reported the patient has had more than one fall since returning home from the hospital and that she is concerned for his safety and him getting weaker. The nurse (Staff C) confirmed that physical therapy was scheduled to evaluate the patient sometime the following week. During an interview on 8/25/23 at 11:05 a.m., the Clinical Manager (Staff B) was queried about the reason for the delay in care for this patient. Staff B reported they try to get out to see the patient within the allotted time, but staffing issues prevent them from doing so at times. An order was sent to the physician to approve the date change for this patient; however, it is still a violation of the regulation. Staff B acknowledged the findings and reported they are doing their best to get the patients scheduled as soon as they can. The Administrator (Staff A) also acknowledged the findings at that time and reported they have been trying to hire more staff to help accommodate their case load.

Integrate all services CFR(s): 484.60(d)(3) Integrate services, whether services are provided directly or under arrangement, to assure the identification of patient needs and factors that could affect patient safety and treatment effectiveness and the coordination of care provided by all disciplines. This ELEMENT is not met as evidenced by: Based on record review and interview, it was determined the agency failed to ensure coordination of care occurred to ensure patient needs were identified and communicated to the appropriate professional in 1 (Patient #17) of 17 records reviewed, resulting in the potential for unmet care needs and negative outcomes. Findings include: P-17: This 69-year-old patient was admitted to home care on 8/4/23 for skilled nursing and physical therapy following surgery for right total hip replacement. During record review on 8/23/23, it was determined the patient mentioned to the physical therapist during her visit on 8/11/23 that she was concerned about an area of skin breakdown on her bottom. The physical therapist told her to let the nurse know at her next appointment. Upon further review of the documentation of the skilled nursing visits on 8/11/23 and 8/18/23, there was no mention of the patient's skin on her bottom being checked on by the nurse. There was also no follow-up in subsequent physical therapy notes or communication notes between the physical therapist and nurse to ensure the issue was addressed. The Clinical Manager (Staff B) was interviewed on 8/25/23 at 11:05 a.m. regarding whether there was documentation to ensure the patient's skin was evaluated. Staff B was unable to find any evidence of this and acknowledged the findings.

Visit schedule CFR(s): 484.60(e)(1) Visit schedule, including frequency of visits by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, record review and interview, the agency failed to ensure a written visit schedule including frequency of visits for each discipline was provided to the patient in 3 (Patient #15, 16, 17) of 7 records with home visits, resulting in the potential for the patient to not be informed of the plan of care or the expected staff visits. Findings include: P-17: This 69-year-old patient was admitted to home care on 8/4/23 for skilled nursing and physical therapy following surgery for a right total hip replacement. During record review on 8/23/23, it was determined the patient was to receive skilled nursing services 1 time a week for 4 weeks, 2 times a month for 1 month and 3 PRN (as needed) visits as well as physical therapy 3 times a week for 2 weeks and 2 times a week for 2 weeks. During a survey home visit on 8/23/23, it was determined the patient's start of care folder included a "Discipline Frequency" form, however, there was no frequency written next to the boxes checked for skilled nursing or physical therapy. The Clinical Manager (Staff B) was interviewed on 8/25/23 at 11:05 a.m. regarding the expectations of this form being filled out and provided to the patient after the start of care. Staff B reported each sheet should have the appropriate disciplines marked as well as the frequency of visits. This form should be placed back in the folder or given to the patient. Staff B was able to find the scanned form in the computer and acknowledged that it was not filled out appropriately. P-16: This 84-year-old patient was admitted to home care on 8/18/23 for skilled nursing and physical therapy following a hospitalization for hyponatremia (low sodium in the blood) and frequent falls. During chart review on 8/23/23, it was determined the patient was to receive skilled nursing 1 time a week for 9 weeks and 3 visits PRN (as needed). He was still waiting for his physical therapy evaluation. During a survey home visit on 8/24/23, the patient's start of care folder was reviewed in search of the "Discipline Frequency" form. There was no form in the folder. The patient's daughter (who has been present and staying with the patient since he was admitted) was queried if she had been given a form that showed frequency of visits and stated she had not. She also reported that no papers had been taken out of the folder since starting care the week before. The patient and his daughter were queried how they know how often home care would come. They stated they receive calls the day before a visit to confirm, but they did not have any written communication. The nurse who performed the visit (Staff C) reported she would have put the form in the folder so wasn't sure where it was. Staff B was queried during an interview on 8/25/23 at 11:05 a.m. regarding this form. Staff B was able to find a scanned copy of it in the electronic medical record that was filled out but was unsure as to why there was no form in the chart or given to the patient. P-15: This 67-year-old patient was admitted to home care on 8/17/23 for skilled nursing and physical therapy due to hidradenitis suppurativa (a chronic skin condition) and cellulitis of the groin. During chart review on 8/23/23, it was determined the patient was to receive skilled nursing services 2 times a week for 2 weeks, 1 time a week for 6 weeks and 3 visits PRN (as needed). He was scheduled to start physical therapy on 8/24/23. During a survey home visit on 8/24/23, the patient's start of care folder was reviewed in search of the "Discipline Frequency" form. There was no form in the folder. The patient's wife was queried if she had been given a form that showed frequency of visits and she stated she had not. She also reported that she had not removed any papers from that folder since starting care the week before. Patient's wife was also queried how they know how often home care would come and she stated she thought it was once a week. She denied receiving paperwork that stated the planned frequencies. Staff B was queried during an interview on 8/25/23 at 11:05 a.m. regarding this form. She was able to find a scanned copy of it in the electronic medical record that was filled out but was unsure as to why there was no form in the chart or given to the patient. Findings were reviewed again and acknowledged by the Administrator (Staff A) and Staff B during the exit interview on 8/25/23 at 12:15 p.m.

Patient medication schedule/instructions CFR(s): 484.60(e)(2) Patient medication schedule/instructions, including: medication name, dosage and frequency and which medications will be administered by HHA personnel and personnel acting on behalf of the HHA. This ELEMENT is not met as evidenced by: Based on observation, interview, and record review, the agency failed to ensure written medication instructions including the medication names; dosages; and frequencies, were provided to the patient and caregiver for 1 of 7 (P-4) patients for which a home visit was conducted resulting in the potential for medication errors with poor patient outcomes. Findings include: P-4: This 87-year-old patient was admitted to the agency on 8/22/23 with diagnoses which included high blood pressure; compression fracture of the spine; and history of falls. A joint home visit was conducted with an agency home health aide on 8/24/23. During the visit, the agency admission packet folder was viewed with assistance from the patient’s caregiver. A blank medication list was found within the admission packet folder and no other list of medications taken by the patient could be found in the folder. Upon noting this, the caregiver was queried to whether the agency had provided written medication instructions for the patient’s current medications which included medication names; dosages; and frequencies. The caregiver reached into a bag on the kitchen table and pulled out a folded-up, handwritten list of medications and stated that she (the caregiver) made this list of medications herself and no other medication list had been written out or provided by agency staff. 0n 8/25/23 at 12:10 p.m., the Case Manager (Staff B) viewed the electronic medical record and the uploaded documentation from the patient’s start of care visit and stated that she was not able to find any evidence that the agency had provided a written copy of medications with instruction for use that would have been left in the home for the patient and caregiver. Staff B also stated that the medication list should have been written out and left in the home for the patient and caregiver. This finding was reviewed and acknowledged by the Administrator on 8/25/23 at 12:30 p.m.

Goals in the patient's plans of care CFR(s): 484.110(a)(3) Goals in the patient's plans of care and the patient's progress toward achieving them; This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure patient goals were specific and measurable in the patient's plan of care due to lack of baseline information in the evaluation in 1 (Patient #17) of 17 records reviewed, resulting in an inability to accurately assess patient status and need for continuing care. Findings include: P-17: This 69-year-old patient was admitted to home care on 8/4/23 for skilled nursing and physical therapy services following surgery for a right total hip replacement. During record review on 8/23/23, it was determined that a goal was set for hip range of motion that stated, "Patient will improve range of motion of right hip abduction to 40 degrees and hip extension to 10 degrees." There was no evidence in the physical therapy evaluation dated 8/4/23 that baseline measurements were taken of the right hip to ensure appropriate goal setting. During further record review, it was noted that a goal was set for hip strength that stated, "Patient will increase strength from initial MMT (manual muscle test) score in order to perform specific functional task as evidenced by stated improvement in MMT score and specific functional task performed - right hip strength to 4/5." There was no evidence in the physical therapy evaluation dated 8/4/23 that baseline measurements were taken of the right hip to ensure appropriate goal setting. During an interview on 8/25/23 at 11:05 a.m., the Clinical Manager (Staff B) was queried regarding baseline measurements in the physical therapy evaluation. Staff B reported she did not see any baseline measurements made for right hip range of motion or strength and acknowledged the findings.

Discharge and transfer summaries CFR(s): 484.110(a)(6)(i-iii) (i) A completed discharge summary that is sent to the primary care practitioner or other health care professional who will be responsible for providing care and services to the patient after discharge from the HHA (if any) within 5 business days of the patient's discharge; or (ii) A completed transfer summary that is sent within 2 business days of a planned transfer, if the patient's care will be immediately continued in a health care facility; or (iii) A completed transfer summary that is sent within 2 business days of becoming aware of an unplanned transfer, if the patient is still receiving care in a health care facility at the time when the HHA becomes aware of the transfer. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to ensure a completed discharge summary was sent to the primary care practitioner within 5 days after discharge in 1 of 5 (P-5) sample discharge records reviewed potentially resulting in unmet patient care needs due to a lack of coordination of patient care. Findings include: P-5: This 85-year-old patient was admitted to the agency on 2/27/22 with diagnoses which included high blood pressure and wounds to buttocks. The medical record was reviewed on 8/24/23. It was noted during review that the patient was discharged from the agency on 8/25/22 and a Discharge Outcome and Assessment Information Set (OASIS) was completed by the nurse on 8/25/22. There was no documentation in the medical record indicating that a completed discharge summary had been sent to the primary care practitioner within 5 days of the discharge. During interview with the Clinical Manager (Staff B) on 8/25/23 at 12:10 p.m., Staff B viewed the patient’s electronic medical record and stated that she was not able to find evidence that a discharge summary had been sent to the primary care practitioner. This finding was reviewed and acknowledged by the Administrator on 8/25/23 at 12:30 p.m.